COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX64121330 
C46  .Sc3  1919     Modem  medicine  and 


RECAP 


MEDICINE 


{JOM]i  MOJ3KRN  RJiMEDlES 


I'UOMAS     nODl.HY     SCOTT 


S15C0ND  liDlTlON 


Columbia  ®mtjergitp\^\5 

in  tfje  €itv  of  JSettJ  ^ovk 

COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


Reference  Library 

Given  by 


MODERN   MEDICINE 

AND 

SOME   MODERN   REMEDIES 


MODERN  MEDICINE 

AND 

SOME   MODERN   REMEDIES 

Practical  Notes  for  the  General  Practitioner 


BY 

THOMAS    BODLEY     SCOTT 

AUTHOR  OF  "the  ROAD  TO  A  HEALTHY  OLD  AGE  " 


WITH   A   PREFACE 

BY 

SIR   LAUDER   BRUNTON,  Bart.,   F.R.S. 


SECOND   EDITION 


PAUL   B.   HOEBER 

67    &   69    EAST    59TH   STREET 

NEW   YORK 

1919 


[P?  luted  in  England] 


AUTHOR'S  APOLOGY 

The  "  Horse  Subsecivse  '*  of  a  busy  doctor  are 
not  many,  nor  are  they  consecutive.  If  one 
could  sit  down  at  one's  leisure  and  write 
currente  calamo,  a  more  finished  and  better 
thought-out  argument  could  be  produced,  but 
one  not  necessarily  more  convincing.  For  these 
essays,  which  have  been  written  at  odd  times 
and  in  odd  places,  I  know  I  can  claim  the 
forbearance  and  sympathy  of  my  professional 
brethren,  for  they  too  are  the  servants — thank 
God  the  willing  servants — of  their  patients 
night  and  day. 


T.  B.  SCOTT. 


Bournemouth, 

February  191 6. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/modernmedicinesobOscot 


PREFACE 

When  the  library  of  Louvain  with  its  precious 
books  and  priceless  manuscripts  was  destroyed 
in  August  1 9 14,  in  the  name  of  their  god 
"  Kultur  "  by  the  modern  Huns,  more  treacher- 
ous, more  unspeakably  mean  and  more  incred- 
ibly evil,  than  their  prototypes,  a  cry  of  horror 
and  execration  rose  from  the  civilised  world. 
For  this  was  not  only  an  outrage  on  Belgium, 
a  country  which  the  Huns  had  pledged  them- 
selves to  respect ;  it  was  a  crime  against 
humanity — for  the  treasures  of  learning  then 
destroyed  were  a  part  of  the  heritage  of  man- 
kind. Great  and  widespread  was  the  lamenta- 
tion, and  cause  enough  there  was  for  it,  for  these 
lost  treasures  can  never  be  entirely  replaced. 
Yet  we  see  every  day  around  us  a  loss  of  learning 
going  on  greater  than  occurred  in  the  destruc- 
tion of  Louvain,  and  no  one  seems  to  perceive 
it  or  hft  a  finger  to  prevent  it.  No  doubt  some 
men  outlive  their  usefulness,   but  many  die 


vu 


viii  PREFACE 

just  when  they  are  at  their  best,  just  when 
they  have  accumulated  stores  of  wisdom  and 
have  learned  both  what  to  do  and  how  to  do  it. 
Most  of  these  men  carry  their  knowledge  and 
power  with  them  to  the  grave,  and  leave  no 
record  behind  them  by  which  posterity  might 
profit. 

In  former  days  this  complete  loss  was 
prevented  to  a  great  extent  by  the  system  of 
apprenticeship.  By  this  system  a  master  im- 
parted to  his  apprentices  as  much  as  he  could 
of  the  secrets  of  his  craft,  and  ensured  as  much 
as  possible  that  the  best  methods  he  had 
learned  from  his  own  master,  or  discovered  for 
himself,  should  be  transmitted  in  full  measure 
to  his  pupils,  who  in  their  turn  should  do  as 
much  for  theirs. 

But  this  system  with  all  its  advantages 
has  in  great  measure  disappeared,  and  serious 
has  been  the  loss. 

Perhaps  no  art  or  craft  has  suffered  more 
than  that  of  medicine  by  this  change.  It  is 
true  that  the  loss  has  been  compensated,  and 
more  than  compensated  on  the  whole^  by  the 
enormous  advances  of  medical  science.  Our 
knowledge  of  the  causes  of  disease,  our  power 
to  recognise  their  presence,  and  our  knowledge 


PREFACE  ix 

of  the  action  of  drugs,  have  increased  so  enor- 
mously within  the  last  fifty  years  that  medicine 
may  now  almost  boast  of  being  an  exact 
science. 

But  while  medicine  as  a  science  has  gained, 
there  has  been  loss  in  medicine  as  an  art — loss 
in  the  method  of  applying  all  this  knowledge 
to  the  treatment  of  individual  patients.  One 
man  may  know  theoretically  all  about  the  laws 
of  perspective  and  the  harmony  of  colours, 
and  yet  be  unable  to  produce  anything  but  a 
daub,  while  another  who  is  completely  ignorant 
theoretically  may  be  able  to  paint  a  charming 
picture.  In  like  manner  a  man  may  be  able 
to  pass  the  most  stringent  examination  with 
honours  in  pathology,  pharmacology  and  diag- 
nosis, yet  he  may  prove  almost  useless  by  the 
bedside,  because  he  tries  to  treat  the  disease, 
and  not  the  patient.  On  the  other  hand  a 
man  with  far  less  theoretical  knowledge  but 
more  common  sense  and  savoir-faire  will  win 
his  patient's  confidence,  give  him  comfort  and 
ease  both  of  mind  and  bod}^,  and  even  rescue 
him  from  a  condition  so  serious  as  to  be  well- 
nigh  hopeless. 

The  ideal  physician  is  the  man  who  combines 
theoretical  knowledge,  practical  experience  and 


X  PREFACE 

savoir-faire.  In  the  absence  of  apprenticeship 
the  best  conditions  for  obtaining  this  highly 
desirable  combination  are  those  of  a  general 
practitioner  who,  after  a  thorough  training  as 
a  student,  has  an  active  practice  amongst 
patients  sufficiently  wealthy  to  enable  him  to 
call  the  best  specialist  or  specialists  into  con- 
sultation in  any  difficult  case.  He  thus  learns 
all  they  can  teach  him  either  of  theory  or 
practice,  he  has  an  opportunity  of  testing  the 
correctness  of  both  by  watching  the  progress  of 
his  patient,  and  from  his  relations  with  the  sick 
person  he  becomes  a  friend  both  of  the  patient 
and  the  family. 

It  is  most  unfortunate  that  such  men  rarely 
write  down  the  results  of  their  experience,  for 
they  are  too  much  engaged  in  their  daily  work 
while  they  are  in  practice,  and  instead  of 
retiring  early,  so  as  to  have  a  few  years'  leisure 
before  they  die,  they  are  apt  to  work  to  the 
very  last  and  die  in  harness. 

It  is  a  most  welcome  occurrence  when  a  man 
fully  qualified  to  do  so  writes  down  the  ripe 
experience  of  his  life  so  as  to  help  his  fellow- 
workers,  both  general  practitioners  and  con- 
sultants, who  one  and  all  may  learn  from 
him. 


PREFACE  xi 


I  feel  myself  much  honoured  by  the  request 
of  my  friend  Dr.  T.  B.  Scott  to  write  a  preface 
to  his  book,  and  in  doing  this  I  gladly  acknow- 
ledge myself  to  be  one  of  the  consultants  of 
whom  I  have  just  spoken,  and  to  thank  him 
for  the  knowledge  I  have  gained  from  reading 
his  book. 

Few,  if  any,  will  rise  from  its  perusal  without 
knowing  something  of  which  they  were  pre- 
viously ignorant ;  and  if  other  men  qualified 
like  Dr.  Scott  will  follow  the  example  he  has 
set,  and  write  down  the  results  of  their  experi- 
ence, the  medical  profession  will  gain  greatly 
in  knowledge  and  patients  will  benefit  greatly 
by  improvement  in  treatment. 


Lauder  Brunton. 


CONTENTS 


Author's  Apology 

PAGE 

V 

Preface     

vii 

List  of  Authorities 

XV 

Introduction     .... 

I 

I.    Disorders  of  the  Heart   . 

7 

11.   Arterio-sclerosis 

49 

HI.   Therapeutic    Speculations 

and 

Doubts    .... 

97 

IV.   Chronic   Bronchitis   and    Bron- 

chial Asthma  . 

i8o 

Xlll 


AUTHORITIES 

Allbutt,   Clifford,  Dr.  :    Dictionary  of  Medicine, 

vol.  v.,  p.  961. 
BiEDL,  Professor  :  Internal  Secretory  Organs,  pp.  70, 

75,  91,  188,  250. 
Brunton,  Lauder,  Sir  :    Therapeutics  of  the  Circula- 
tion, pp.  89,  90,  295,  307,  335,  433  ;   Lancet,  vol. 

vii.,  p.  24,  1915. 
Elliott,  Dr.  :    Practitioner,  February,  1915. 
Gaskell,  Dr.  :   Article  on  "  Contraction  of  the  Heart 

Muscle  "  in  Schafer's  Textbook  of  Physiology. 
Mackenzie,    James,    Dr.  :     Diseases    of   the   Heart, 

pp.  20,  28,  72,  78,  341,  377. 
Murray,  George,  Dr.  :   Practitioner,  January,  191 5. 
Oliver,   George,  Dr.  :    Studies  in  Blood  Pressure, 

pp.  82,  109,  189. 
Paton,  Noel,  Dr.  :    Practitioner,  February,   1915. 
Schafer,  Edward,  Sir  :   An  Introduction  to  the  Study 

of  the  Endocrine   Glands,    Stanford   University, 

California. 
Short,  Rendle,  Dr.  :    The  Newer  Physiology,  third 

edition,  pp.  82,  144. 
Whitla,  Dr.  :   Practice  of  Medicine,  vol.  i.,  p.  633. 


XV 


ESSAYS  ON  PRACTICAL 
MEDICINE 

INTRODUCTION 

The  experiences  and  opportunities  for  experi- 
ences that  belong  to  hospital  physicians  and  to 
general  practitioners  differ  so  much,  that  the 
study  and  treatment  of  disease  from  their 
several  points  of  view  differ  also.  As  a  rule 
the  hospital  physician  is  an  able  writer  and  a 
skilled  recorder,  while  the  general  practitioner 
has  either  not  the  time,  or  else  not  the  courage, 
to  record  his  experiences  and  results,  and  so 
much  valuable  material  and  knowledge  are  lost 
to  the  world.  A  great  general  will  take  care 
to  get  into  touch  with  his  non-commissioned 
officers  and  men,  as  well  as  with  his  officers,  and 
will  make  use  of  the  experiences  and  observa- 
tions of  both  classes.  Not  a  few  of  our  own  wiser 
hospital  physicians  refuse  to  sit  in  the  seat  of 
the  scornful,  and  listen  carefully  to  what  we 
I 


'2      ESSAYS   ON   PRACTICAL   MEDICINE 

have  to  say  and  openly  acknowledge  their  in- 
debtedness to  us.     It  has  been  too  much  the 
habit  of  our  profession  to  rely  almost  entirely 
on  hospital  records  and  results,  both  of  which 
are  necessarily  obtained  under  rather  abnormal 
and  favourable  circumstances,  and  it  is  difficult 
for  the  ordinary  hospital  physicians  to  gauge 
the  difficulties  in  diagnosis,  in  prognosis,  and 
in  treatment  that  meet  their  humbler  brethren. 
Dr.  James  Mackenzie  in  his  invaluable  work 
on  diseases  of  the  heart  says:  "  The  investigators 
in  hospital  wards  and  laboratories  have  little 
idea  of  the  difficulties  the  general  practitioner 
has  to  encounter.  He  must  ever  be  on  the  alert, 
prepared  to  make  an  observation  at  any  hour 
of  the  day  and  night ;   attacks  of  illness  which 
may  arise  suddenly  must  find  him  prepared  to 
take  advantage  of  his  opportunities."    He  goes 
on  to  say,  "  The  little  I  have  been  able  to  do 
in  this  respect  has  but  opened  my  eyes  to  the 
extraordinarily  rich  field  for  investigation  that 
lies  before  the  general  practitioner." 

The  position  that  Dr.  Mackenzie  has  won 
for  himself  and  the  magnificent  work  he  has 
done,  though  for  years  only  a  general  practi- 
tioner, should  be  a  great  encouragement  and 
incentive  to  us  all. 


INTRODUCTION 


Why,  then,  should  we  keep  our  lights  hidden  ? 
Our  light,  like  that  of  true  religion,  is  meant  to 
shine  before  men,  and  to  enable  both  them  and 
us  to  glorify  our  Father  which  is  in  heaven. 
Our  work,  if  faithfully  done,  will  surely  lead 
towards  the  fulfilment  of  His  increasing  pur- 
pose, which  I  take  to  be  the  evolution  of  human 
perfection. 

We  have  some  good  periodicals  that  are 
ready  to  accept  any  papers  of  merit  and 
originality.  It  is  we  who  see  disease  in  its 
inception,  in  its  maturity  and  in  its  end.  We 
may  not  have  the  scientific  knowledge  and 
appliances  that  belong  to  a  well-equipped  hos- 
pital, but  in  our  knowledge  of  practical  thera- 
peutics we  are  often  in  advance  of  the  hospital 
physician  :  that  this  should  be  so  is  no  honour 
to  us,  and  no  shame  to  them,  for  we  are  in 
much  closer  relationship  with  our  patients,  and 
we  can  observe  more  accurately  the  successes 
and  the  failures  of  our  methods.  We  have  to 
treat  disease  in  its  natural  habitation  and  sur- 
roundings, and  not  in  the  unaccustomed  quiet 
and  luxury  of  a  hospital  ward.  As  our  diffi- 
culties are  greater,  so  must  we  improve  our 
weapons  and  resources.  Our  teachers  and 
examiners  are  devoted,  hard-working,  excellent 


4      ESSAYS  ON  PRACTICAL   MEDICINE 

men,  and  good  doctors  up  to  their  lights,  but 
they  have,  from  the  very  nature  of  their  posi- 
tion, their  hmitations. 

I  think  perhaps  where  we  are  most  deficient 
is  in  accuracy  of  diagnosis.  Sometimes  we  are 
hurried,  and  often  wearied,  and  so  come  to  a 
conclusion  too  hastily  ;  sometimes  we  have  to 
use  the  stethoscope  in  such  noisy  rooms  that 
important  points  are  missed  or  misread. 
Whether  this  be  so  or  not,  accuracy  of  diag- 
nosis must  be  the  groundwork  of  success.  This 
may  entail  more  time  and  trouble  than  we  seem 
to  have  to  spare,  but  it  is  so  essential  that  in  the 
end  no  time  will  have  been  lost.  We  must  not 
hesitate  to  call  in  other  aids,  especially  the  aid 
of  the  bacteriologist  and  in  some  cases  that  of 
the  specialist.  A  wise  general  practitioner  who 
had  a  very  large  club  and  contract  practice  once 
said,  "  The  only  way  to  make  contract  practice 
pay  is  to  find  out  what  is  really  the  matter  with 
your  patients,  give  them  the  best  medicines 
you  know,  even  if  they  be  costly,  and  get  them 
off  your  list  as  quickly  as  possible."  That  con- 
tains not  only  worldly  wisdom,  but  the  true 
spirit  also  of  altruism  and  righteousness.  Good 
and  honest  work  will  always  pay  in  the  end. 
These  thoughts  must  lead  us  on  to  see  the 


INTRODUCTION 


enormous  importance  of  a  sound  knowledge  of 
therapeutics ;  for  mere  accuracy  of  diagnosis 
is,  as  I  have  said  before,  only  the  groundwork, 
the  foundation  of  our  successful  building. 
Our  one  and  only  objective  must  be,  to  cure 
disease,  and  in  so  doing  to  relieve  suffering  and 
prolong  life.  In  the  great  campaign  against 
disease,  we  should  be  the  eyes  and  ears  of  the 
army  ;  the  scouts,  and  in  treatment  often  the 
pioneers. 

We  should  welcome  the  wisdom  that  comes 
from  above,  from  our  teachers  and  lecturers, 
but  we  should  not  be  enslaved  by  it ;  we  should 
rather  prove  it  and  improve  it. 

Failures  must  of  course  come  to  us,  but  we 
should  never  allow  oiurselves  to  look  on  failure 
as  inevitable.  We  must  storm  and  go  on  storm- 
ing even  what  seem  to  be  impossible  heights. 

I  publish  this  little  book  in  the  hope  that  it 
may  be  of  some  help  to  my  fellow  practitioners, 
and  still  more  in  the  hope  that  it  may  induce 
some  of  them  to  follow  my  poor  example. 


DISORDERS   OF   THE    HEART 

If  there  is  one  organ  of  the  body  that  we  are 
tempted  to  misread  more  than  another  it  is, 
I  think,  the  heart.  We  are  so  tied  down  by 
traditions  and  conventions  with  regard  to 
heart  affections  that  we  hardly  ever  give  our 
common  sense  full  play.  And  it  is  not  only 
in  conditions  of  evident  disease  that  we  mis- 
interpret, but  also  in  conditions  of  apparent 
health.  One  chief  reason  for  our  errors  is,  I 
think,  the  exclusive  reliance  on  the  stetho- 
scope. In  reality  the  stethoscope  tells  us  but 
a  small  part  of  the  whole  matter.  It  tells  us 
the  condition  of  the  valves  of  the  heart,  and 
this  is,  of  course,  a  thing  we  must  know  ;  but, 
except  in  cases  of  extreme  debility  or  degenera- 
tion, it  tells  us  very  little  of  the  state  of  the 
muscle  of  the  heart  itself,  that  great  driving- 
power  that  keeps  going  our  circulation,  and 
with  it  our  hfe,  and  to  which  the  valves  are. 
only  accessories. 


8      ESSAYS   ON  PRACTICAL   MEDICINE 

As  a  preliminary  to  the  intelligent  study  of 
heart  disease  we  must  get  these  axioms  firmly 
into  our  minds  :  first  that  the  heart  is  an  organ 
with  enormous  natural  powers  of  recuperation, 
and  second  that  it  is  an  organ  with  a  marvellous 
power  of  adapting  itself  to  meet  not  only 
emergencies,  but  also  permanently  altered 
conditions.  We  must  all  of  us  have  come 
across  many  cases  in  our  Hves,  in  which  there 
was  marked  valvular  abnormality,  yet  in  which 
no  symptoms  of  ordinary  heart  disease  showed 
themselves  during  life.  I  think  the  loudest 
aortic  systolic  murmru  I  ever  heard  was  in  an 
old  lady,  who  with  the  exception  of  rheumatism 
had  remarkably  good  health  and  who  Hved  till 
she  was  ninety-three. 

To  give  very  shortly  a  clear  idea  of  the 
functions  and  special  characteristics  of  the 
heart  muscle  I  give  this  extract  from  Dr. 
Mackenzie's  book  on  diseases  of  the  heart : 
"  I  therefore  suggest  as  a  working  hypothesis, 
that,  in  the  evolution  of  the  heart  muscle 
fibres,  certain  functions  of  the  primitive  cell 
were  retained,  some  of  these  being  more  de- 
veloped than  others  according  to  the  duties  the 
fibres  had  to  perform,  so  that  while  they  have 
come  to  resemble  muscle  fibres,  they  never- 


DISORDERS   OF    THE   HEART  g 

theless  retain,  in  a  varying  degree,  some  func- 
tions which  are  highly  speciaHsed  in  the  nerve 
ceU." 

The  special  functions  which  Gaskell  has 
demonstrated  are  five  : 

1.  The  power  of  producing  a  stimulus 

which  can  excite  the  heart  to 

contract       ....     Stimulus  production 

2 .  The  power  of  being  able  to  receive 

a  stimulus   ....     Excitability 

3.  The  power  of  conveying  a  stimu- 

lus from  fibre  to  fibre  .     Conductivity 

4.  The  power  of  contracting,  when 

stimulated   ....     Contractibility 

5.  The  power  to  retain  a  certain 

amount   of   contraction   even 

when  the  activity  has  ceased  .     Tonicity 

For  the  elaboration  and  description  of  these 
five  functions,  which  all  go  to  form  the  perfect 
action  and  function  of  the  heart,  I  must  refer 
my  readers  to  Dr.  Mackenzie's  book,  or  to 
Gaskell's  article  on  "  The  contraction  of  the 
heart  muscle  "  in  Schafer's  text-book  of  physi- 
ology. Without  this  physiological  explanation 
and  knowledge  it  is  difficult,  nay  impossible, 
to  rightly  weigh  the  value  of  abnormalities 
in  the  heart's  action  in  clinical  work. 

The  relative  importance  of  different  valvular 
diseases  varies,  without  doubt ;  but  that  is  a 
point  which  I  shall  touch  on  later.    My  con- 


lo     ESSAYS  ON  PRACTICAL   MEDICINE 

tention  is  this :  that  the  man  who  in  heart 
affections  trusts  only  to  the  stethoscope  is, 
of  necessity,  sure  to  come  to  grief,  for  he  is 
gauging  one  side  only,  and  that  not  the  most 
important  side,  of  a  complicated  problem. 
The  test  of  a  heart's  working  power  Hes  not  in 
the  perfection  of  this  or  that  valve,  but  in  the 
fact  of  that  heart  being  able  to  meet  the  demand 
of  the  individual's  Hfe  or  not ;  and  in  testing 
this  the  stethoscope  will  help  but  little. 
Careful  observation  of  the  patient's  breathing 
and  powers  of  endurance  will  help,  far  more, 
to  show  what  amount  of  reserve  power  remains 
in  the  heart  muscle  and  what  the  prospects  are 
of  that  muscle  being  able  to  respond  to  new 
demands.  I  saw  an  old  man  lately,  who 
greeted  me  thus :  "  To-day  is  a  very  im- 
portant anniversary  in  my  life.  It  is  just  fifty 
years  ago  that  I  was  rejected  for  life  insurance 
on  account  of  heart  disease."  Now  a  case 
like  this  has  a  humorous  side,  but  it  also  brings 
our  learned  profession  into  ridicule  and  dis- 
repute. 

For  further  guidance — and  I  think  it  would 
be  hard  to  exaggerate  their  value — we  have  the 
sphygmograph  and  the  sphygmo-manometer 
(I  am  not  laying  stress  on  the  electro-car dio- 


DISORDERS   OF   THE   HEART  u 

graph,  as  that  is  practically  out  of  the  reach  of 
the  ordinary  doctor)  ;  these  will  help  far  more 
than  the  stethoscope  to  get  a  clear  and  just 
understanding  of  the  heart's  condition.  It  is 
very  rarely,  for  example,  that  the  "  pulsus 
alternans,'*  which  may  be  of  great  diagnostic 
importance,  can  be  detected  by  the  finger  ;  the 
sphygmograph  alone  can  prove  its  existence. 
Arterial  tension  again,  high  or  low,  can  only 
be  at  all  accurately  tested  by  the  manometer, 
and  in  the  treatment  of  a  failing  heart,  of  what 
paramount  importance  it  is  to  recognise  the 
true  condition  !  To  learn  the  use  of  these 
instruments  takes  some  time  and  trouble,  but 
it  is  our  manifest  duty  to  do  it.  When  we  are 
able  to  use  them  we  shall  be  able  to  do  far  more 
for  our  patients,  for  our  reputation,  and  for  our 
peace  of  mind.  Nothing  is  more  unsatisfactory 
to  an  honest  mind,  than  to  feel  that  he  is  trying 
to  solve  a  problem,  which  is  insoluble,  only 
because  of  the  twilight  ignorance  of  his  own 
mind,  or  of  the  imperfection  of  his  weapons. 
In  general  practice,  especially  among  busy 
working  folk,  these  cases  of  heart  disease  or 
heart  failure  form  a  large  part  of  our  practice, 
and  their  continuance  leads  to  much  disability 
and  misery.     If  we  can  get  hold  of  them  in 


12     ESSAYS   ON   PRACTICAL   MEDICINE 

their  early  stages  and  treat  them  wisely,  we 
can  do  very  much  not  alone  to  prolong  life  but 
to  maintain  a  good  output  of  work,  and  what 
that  means  to  working  people  those  only  who 
have  lived  among  them  know.  Let  us  then  cast 
aside  our  old  preconceived  ideas,  which  were 
often  not  in  accordance  either  with  scientific 
knowledge  or  with  experience,  and  using  every 
weapon  of  modern  science,  let  us  wage  a  new 
warfare  in  the  spirit  of  confidence  and  hope. 
Many  of  our  older  teachers  and  brethren  will 
quietly  sneer,  and  throw  cold  water  on  our 
enterprises,  but  we  must  comfort  ourselves  with 
the  thought  that  the  old  proverb  about  putting 
new  wine  into  old  wine-skins  still  holds  good. 
In  the  study  and  treatment  of  heart  diseases 
we  must  most  strongly  bear  in  mind  the  fact 
that  the  natural  heart  under  ordinary  conditions 
is  only  working  at  part  of  its  power,  and  that 
there  is  always  a  considerable  reserve  of  latent 
force.  This  varies,  of  course,  in  different 
individuals,  and  in  the  same  individual  under 
different  circumstances.  It  is  this  latent  force 
that  enables  us  in  health  to  make  unusual  and 
prolonged  physical  efforts,  and  it  is  the  greater 
or  lesser  amount  of  this  latent  force  that 
enables  the  heart  under  conditions  of  disease  to 


DISORDERS   OF   THE   HEART  13 

meet  and  overcome  the  new  difficulties,  or  to 
fail  in  the  attempt.  In  health,  by  wise  physical 
exercises,  and  by  what  we  call  training,  the 
latent  force  can  be  enormously  increased,  so 
that  marvellous  feats  of  effort  and  endurance 
can  be  performed.  In  disease  also  the  amount 
of  latent  force  can  be  much  increased  or  at 
least  preserved  by  wise  exercise  and  training. 
This  we  see  constantly  as  the  result  of  the  so- 
called  Swedish  exercises  and  of  those  of  Nau- 
heim.  With  these  facts  firmly  in  our  minds, 
we  must  approach  each  case  of  heart  disease 
not  so  much  from  the  valvular  side,  the  side 
of  obstruction  or  of  leakage,  as  from  the  side  of 
the  heart  muscle  itself.  The  stethoscope  will 
tell  us  more  or  less  accurately  the  nature  of 
the  valvular  defect,  but  not — which  is  more 
important — the  power  of  the  great  and  com- 
plicated organ  to  meet  that  defect. 

We  must  study  the  whole  problem  in  a  large 
spirit,  and  our  treatment  must  be  directed  to 
placing  the  patient  and  his  heart  under  the  best 
conditions  for  recovery,  or,  if  that  be  not  pos- 
sible, for  a  natural  readjustment  of  the  heart's 
work.  Many  a  heart  will  do  this  for  itself  if  it 
only  has  the  chance.  Rest,  it  goes  without  say- 
ing, must  be  the  first  step,  but  to  rest  a  heart 


T4     ESSAYS   ON   PRACTICAL   MEDICINE 

is  not  quite  so  simple  an  affair  as  resting  a  limb. 
Staying  in  bed,  or  in  the  recumbent  position,  is 
of  course  good  up  to  a  certain  point ;  but  the 
heart  has  to  go  on  working  and  pumping  the 
blood  unceasingly,  and  it  often  can  do  this 
better  if  the  patient  change  the  position  from 
time  to  time.  If  by  rest  in  one  position  the 
lungs  get  into  a  state  of  hypostatic  congestion, 
the  right  ventricle  has  extra  work  to  do  and  the 
balance  of  the  whole  cardiac  and  respiratory 
system  gets  upset.  Stagnation  of  the  portal 
circulation  will  soon  add  another  difficulty  : 
comparative,  not  complete,  rest  is  all  one  can 
give  the  heart,  and  to  give  that  in  the  best  way 
common  sense  and  individual  observation  must 
be  largely  used.  We  all  know  how  a  patient 
with  cardiac  dyspnoea  longs  to  change  his 
position  from  time  to  time,  and  Nature  no  doubt 
tells  him  aright.  The  great  things  to  avoid  in 
such  a  case  are  hurry  and  straining  ;  stooping 
to  pick  up  something,  or  to  lace  boots,  will  often 
bring  on  acute  distress.  The  physician  can  help 
this  heart  to  get  rest  considerably  by  removing 
obstructions  to  the  circulation  of  blood,  by 
keeping  the  portal  circulation  free,  and  by 
encouraging  the  thorough  action  of  the  bowels 
and  kidneys.     It  is  marvellous  to  see  a  tired, 


DISORDERS   OF   THE   HEART  15 

overworked  and  failing  heart  coming  back  to 
efficiency  and  comfort  under  the  famous  old 
pill,  which  both  Guy's  and  St.  Bartholomew's 
claim,  of  mercury,  squills  and  digitalis  :  the 
mercury  steadily  stimulates  the  liver,  and  the 
squill  and  digitalis  both  act  on  heart  and 
kidneys.  Experience  has  often  shown  that 
digitalis  without  the  mercury  is  almost  use- 
less in  such  a  case.  If  again  by  the  modern 
methods  of  testing  the  arterial  resistance — viz. 
by  the  sphygmo-manometer — we  find,  as  we  so 
frequently  do,  that  there  is  high  blood-pressure, 
we  can  help  the  heart  greatly  by  reducing  that 
pressure,  and  with  it  the  peripheral  resistance 
to  the  flow  of  arterial  blood.  After  two  or  three 
weeks  of  such  intelligent  rest  treatment,  one 
will  be  able  to  form  a  far  better  idea  of  the  real 
state  of  the  heart ;  one  will  know  how  much 
true  valvular  trouble  exists,  how  much  of  the 
trouble  was  due  to  dilatation,  and  how  much 
to  the  state  of  the  heart  muscle  itself. 

One  speaks  of  these  conditions,  valvular 
disease,  dilatation  and  muscular  weakness,  as 
separate,  but  as  a  rule  they  are  all  three  bound 
up  together  and  are  interdependent.  To  arrive 
at  this  knowledge  one  must,  besides  using  the 
stethoscope,  observe  carefully  the  position  of  the 


i6     ESSAYS   ON   PRACTICAL    MEDICINE 

heart's  apex  and  the  area  of  cardiac  duUness. 
K  the  murmur  cease  or  lessen  in  intensity ;  if, 
under  rest  and  wise  treatment,  the  dullness 
diminish  and  the  apex-beat  come  gradually 
back  to  its  normal  position,  one  will  reasonably 
hope  that  the  heart's  disorder  was  due  chiefly 
to  exhaustion  of  a  temporary  nature,  and 
that  it  possesses  a  fair  amount  of  reserve 
power.  If,  on  the  other  hand,  the  murmur 
remain  the  same,  and  the  dullness  and  apex-beat 
remain  stationary,  one  will  realise  that  the 
heart's  condition  is  probably  due  to  permanent 
dilatation,  or  to  compensatory  hypertrophy, 
following  a  long-standing  valvular  disease ; 
here  the  history  of  the  patient,  his  former  ill- 
nesses and  his  habits  of  life  will  help  towards 
an  accurate  diagnosis.  If  the  condition  is  one 
of  hj^ertrophy  and  old  valvular  disease,  not 
much  can  be  done  by  treatment,  except  to 
keep  up  the  nutrition  and  strength  of  the  heart 
muscle — we  must  never  forget  that  hyper- 
trophied  muscles  are  particularly  liable  to 
degenerate — iron,  arsenic  and  strychnine,  par- 
ticularly in  combination,  wiU  help  much 
towards  this  end.  Such  hearts,  if  carefully 
nursed,  will  often  last  a  long  time,  but  they  have 
to  Hve  their  life  at  a  rather  low  level.    The  old 


DISORDERS   OF    THE   HEART  17 

proverb  says,  the  strength  of  a  chain  is  the 
strength  of  its  weakest  Hnk,  and  such  patients 
have  to  learn  this  lesson  and  to  order  their  work 
and  energies  in  accordance  with  their  weak  link. 
On  the  other  hand,  one  must  never  discourage 
these  cases.  A  leaky  ship  will  often  make  a  long 
and  successful  voyage,  and  a  heart  with  a  leaky 
valve  will  often  carry  its  owner  to  old  age,  and 
will  help  him  to  do  much  excellent  work.  If 
you  tell  such  a  man  that  he  has  incurable  heart 
disease  (he  may  happily  be  blessed  with  a 
saving  scepticism),  you  will  have  done  your 
utmost  to  ensure  the  accuracy  of  your  prog- 
nosis, though  your  diagnosis  may  have  been 
grievously  wrong.  There  is  no  important  organ 
of  the  body  so  susceptible  to  nervous  and 
mental  influence  as  the  heart ;  hope  will  buoy 
it  up  to  make  renewed  and  often  successful 
efforts,  despair  will  kill  it.  To  support  my 
contention  I  quote  Dr.  James  Mackenzie's 
words :  "  Let  it  always  be  remembered  that 
frequently  sound  and  healthy  hearts  show  a 
murmur,  and  that  it  is  necessary  therefore  to 
seek  for  other  evidences  on  which  to  base  a 
prognosis.  The  heart  failure  which  may  be 
present  depends  upon  so  many  and  so  varied 
conditions — as,  the  extent  of  the  valvular 
2 


1 8     ESSAYS   ON  PRACTICAL    MEDICINE 

lesion,  its  progressive  nature  depending  on 
the  cicatrising  process  affecting  the  valves, 
the  coincident  changes  in  the  muscle  and  in 
the  auriculo-ventricular  bundle,  the  condition 
of  life  of  the  individual — that  no  rule  appUcable 
to  all  cases  can  be  made."  Later  on  he  says  : 
"  Let  no  single  sjmiptom  be  the  ground  for 
forming  an  unfavourable  prognosis.  In  this 
respect,  the  presence  of  a  murmur  has  so  op- 
pressed the  profession  that  a  vast  amount  of 
positive  harm  is  continually  being  done  to 
patients  by  taking  too  seriously  the  prognostic 
significance  of  this  sign.  The  field  of  cardiac 
response  is  the  only  true  and  safe  guide  in  these 
cases.  Even  if  for  the  time  being  that  response 
is  limited,  judgment  should  be  suspended  until 
an  opportunity  has  been  obtained  for  ascer- 
taining to  what  extent  the  heart  muscle  can 
regain  a  store  of  reserve  force."  The  business 
of  a  prophet  is  nearly  at  all  times  a  dangerous 
and  an  unsatisfactory  one,  whether  in  medicine 
or  in  any  other  sphere ;  but,  recognising  our 
fallibility,  it  is  surely  wiser  and  safer  to  err, 
like  Balaam  of  old,  on  the  side  of  blessing  rather 
than  of  cursing,  of  optimism  rather  than  of  pes- 
simism. I  have  no  wish  to  weary  my  readers, 
if  such  there  should  be,  with  a  dissertation  on 


DISORDERS   OF    THE   HEART  ig 


valvular  diseases  of  the  heart  and  their  physical 
signs  ;  they  probably  know  as  much  as  I  do 
about  them,  but  I  think  it  will  be  a  help  to  give 
this  short  summary  of  their  incidence  and  their 
gravity. 

Firstly,  valvular  disease,  excluding  con- 
genital malformations,  is  acquired,  not  in- 
herited. Secondly,  far  the  most  common  cause 
of  chronic  valvular  disease  is  an  infective  pro- 
cess, producing  endocarditis  ;  of  these  infective 
processes  acute  rheumatism  is  the  most  com- 
mon, but  the  poisons  of  enteric  fever,  scarlatina, 
erysipelas  and  gout  may  produce  the  same 
effect.  Syphilis  is  another  cause,  but  probably 
does  not  act  in  quite  the  same  way.  The  only 
other  causes  as  far  as  we  know  of  valvular 
disease  are,  prolonged  and  severe  muscular 
strain  and  in  later  life  atheroma.  The  diseased 
condition  is  primarily  an  inflammatory  thick- 
ening of  the  valves,  which  produces  a  fibrous 
cicatricial  tissue  ;  this  fibrous  tissue  has  a  ten- 
dency, as  life  goes  on,  to  contract.  This  con- 
traction may  never  take  place,  but  if  it  does 
the  symptoms  of  stenosis  or  of  incompetence 
become  more  marked  and  more  serious. 

Thirdly,  diseases  of  the  mitral  valve  form 
more  than  half  of  our  cases,  and  regurgitation 


20     ESSAYS   ON   PRACTICAL   MEDICINE 

is  more  frequent  than  stenosis ;  aortic  regur- 
gitation alone  or  combined  with  aortic  stenosis 
forms  about  one-fifth  of  the  number  ;  ahnost 
any  combination  may  occur,  but  that  of  aortic 
regurgitation  and  mitral  regurgitation  is  the 
most  common.  Diseases  of  the  pulmonary 
valve  are  very  rare  and  not  of  great  moment. 
Tricuspid  regurgitation  is  frequent  as  a  late 
result  of  mitral  disease,  but  is  rarely  due  to 
original  inflammation ;  the  closure  of  this 
valve  is  so  feeble  and  often  so  imperfect  that 
regurgitation  is  probably  frequent  without  any 
physical  symptoms ;  a  strong  evidence  of  the 
existence  of  tricuspid  regurgitation  is  the  occur- 
rence of  the  ventricular  form  of  jugular  and  liver 
pulsation  without  any  detectable  murmur. 
With  regard  to  the  gravity  of  the  different 
valve  affections,  one  must  look  on  the  aortic 
regurgitation  as  the  most  serious,  and  next 
to  it  mitral  stenosis — mitral  regurgitation  and 
aortic  stenosis  not  being  of  quite  such  import- 
ance as  far  as  life  is  concerned  ;  but  even  with 
the  first  two  a  breakdown  can  be  for  a  long 
time  postponed — if  the  heart  muscle  itself 
keeps  up  its  tonicity  and  strength.  The 
Uability  to  sudden  death,  which  is  not  com- 
mon   in    pure    valvular    disease,    is    greater 


DISORDERS   OF    THE   HEART  21 

probably  in  aortic  regurgitation  than  in  any 
other  form. 

Aortic  regurgitation  showing  itself  first  in 
middle  age,  and  not  as  the  result  of  rheumatic 
fever  in  youth,  is  always  very  serious ;  it  is 
generally  the  outcome  of  overstrain  combined 
with  intemperance,  of  syphilis  or  cardio- 
sclerosis, and  is  frequently  foimd  with  com- 
mencing kidney  disease.  Successful  compen- 
sation can  hardly  be  looked  for  in  such  cases, 
and  unless  the  life  can  be  most  carefully  ordered 
an  early  death  must  be  expected.  Anginal 
symptoms  often  appear,  as  the  coronary  ar- 
teries become  involved  in  the  sclerotic  disease, 
Mitral  Stenosis.  Mackenzie  says  :  "  This  is  per- 
haps the  most  common  of  valvular  defects  with 
which  heart  failure  is  associated.  It  is  generally 
the  result  of  acute  rheumatism  or  some  other 
febrile  disease.  The  condition  is  never  recog- 
nised during  the  acute  process  which  induces  it, 
for  this  reason,  that  the  murmur  is  not  pro- 
duced till  the  cicatrising  process  following  the 
inflammation  narrows  the  orifice ;  and,  on 
account  of  its  origin  in  scar  formation,  it  is  often 
a  progressive  lesion.'*  This  clear  statement 
shows  well  the  dangerous  character  of  this 
defect.     We  practically  never  see  it  till  it  is 


22     ESSAYS   ON   PRACTICAL   MEDICINE 

an  accomplished  fact,  and  the  early  symptoms 
then  are  so  slight  that  we  seldom  get  the 
chance  of  giving  the  heart  the  complete  rest  it 
needs ;  in  this  way  it  stands  in  marked  con- 
trast to  mitral  regurgitation.  Still  even  in  this 
affection  the  disease  may  be  non-progressive, 
and  the  patient  may  Hve  to  a  good  old  age  ;  but 
such  cases  must  be  considered  rare.  The  usual 
course  is  steadily  progressive  contraction  of  the 
valves,  and  interference  with  the  work  of  the 
whole  heart ;  and  not  infrequently,  the  chordae 
tendineae  and  the  auriculo-ventricular  bundle 
becoming  involved,  we  get  auricular  fibrillation 
and  other  rhythmical  defects  added  to  the 
already  embarrassed  heart.  With  such  a 
complication  we  need  not  wonder  that  the 
heart  muscle  soon  fails  to  carry  on  its  work. 

The  above  resmne  of  valvular  diseases  is 
meant  only  to  serve  as  a  reminder  of  what  we 
most  of  us  already  know,  but  which  some  of 
us  may  have  in  part  forgotten.  For  the 
minute  discrimination  of  physical  signs,  for  a 
complete  description  of  the  compHcations  that 
so  often  arise,  and  of  alterations  of  rh5rthm, 
such  as  auricular  fibrillation  and  auricular 
flutter,  I  must  refer  my  reader  to  the  more 
modern  textbooks.     It  must  be  seen,   then. 


DISORDERS   OF    THE   HEART  23 

that  our  principal  aim  and  object  must  be  to 
educate  and  strengthen  the  heart  to  stand  up 
against  its  new  difficulties,  and  if  possible  to 
overcome  them.  If  we  are  fortunate  enough 
to  see  the  patient  in  the  acute  or  sub-acute 
stage  of  the  causative  illness,  the  first  thing 
to  give  is  rest,  and  that  as  complete  as  possible. 

In  rheumatic  fever,  we  should  give  salicylate 
of  soda  freely.  I  think  it  is  not  sufficiently 
realised  that  the  beneficial  action  of  salicylate 
is  much  more  certain  if  we  give  bicarbonate  of 
soda  with  it — the  theory  being,  I  believe,  that 
the  salicylate  acts  better  if  the  blood  be 
rendered  alkaline  :  the  proportion  should  be  at 
least  two  of  bicarbonate  to  one  of  salicylate, 
and  perhaps  two  and  a  half  to  one  would  be  a 
better  proportion  still. 

The  old  alkaline  treatment  of  rheumatic  fever 
in  the  pre-salicylic  days  was  chiefly  carried 
out  with  potash  salts  ;  if  we  were  to  use  these 
in  the  large  doses  required,  we  should  run  a 
grave  risk  of  depressing  the  heart  muscle,  this 
effect  of  potash  salts  being  well  established. 
Some  writers  have  doubted  if  salicylates  have 
any  direct  action  on  endocarditis.  It  is  a 
thing  impossible  to  prove,  but  I  think  the 
logical  assumption  should  be  this — that  a  drug 


24     ESSAYS   ON   PRACTICAL    MEDICINE 

which  can  indubitably  relieve  and  cut  short 
rheumatic  inflammation  of  s3movial  membranes 
should  have  some  similar  action  on  inflamed 
endocardium  arising  from  the  same  poison, 
and  further,  that  a  drug  which  indubitably 
shortens  the  duration  of  the  disease  should  by 
so  much  lessen  the  risk  and  extent  of  endo- 
cardial complication.  Salicylate  and  the 
bicarbonate  of  soda  should  be  kept  going  for 
some  time  after  fever  has  gone,  but  at  steadily 
increasing  intervals.  In  such  cases,  when  signs 
of  valvular  implication  have  appeared,  very 
prolonged  rest  is  most  advisable  ;  three  months 
in  bed  or  on  the  sofa  is  none  too  long  in  most 
cases.  This  gives  the  heart  muscle  time  to 
recover  its  strength,  and  also,  which  is  most 
important,  gives  the  inflammatory  process  in 
the  endocardium  time  to  subside.  During  the 
period  of  rest,  even  if  there  be  irregular  action 
of  the  heart  and  signs  of  dilatation,  I  think 
the  extrinsic  vegetable  heart  tonics  should  be 
given  with  great  caution,  for  any  drug  that 
increases  peripheral  contraction  of  the  arterioles 
throws  more  work  on  the  heart,  and  perhaps 
more  than  defeats  its  object.  I  allude  chiefly 
to  digitalis,  strophanthus,  convallaria,  and 
spartein.     If  there  be  faintness  and  respiratory 


DISORDERS   OF    THE   HEART  25 

distress,  strychnine  may  be  given  hj^odermic- 
ally  in  big  doses.  This  rule  about  heart  tonics 
applies,  I  think,  quite  as  strongly  in  those  condi- 
tions of  heart  feebleness  which  we  find  as  the 
result  of  diphtheria,  enteric,  scarlet  fever,  and 
erysipelas.  Rest  and  strychnine  are  here,  too, 
most  important.  Is  this  cardiac  weakness, 
and  the  muscle  degeneration  which  causes  it, 
the  direct  result  of  the  infection  ?  or  is  it  due 
to  something  lacking  in  the  internal  secretions  ? 
My  own  belief  is  that  the  failure  of  the  supra- 
renal secretion  is  at  least  a  contributory  cause. 

The  following  are  extracts  from  Biedl's  book 
on  the  internal  secretory  organs.  "  According 
to  Langlois  the  amount  of  the  active  substance 
which  raises  blood-pressure  is  apparently  un- 
changed in  the  hypersemic  supra-renal ;  while 
after  chronic  infective  conditions,  the  capsule, 
though  increased  to  three  or  four  times  its 
original  volume,  yields  extracts  which  are 
totally  inactive.  According  to  Luksch  the 
suprarenals  of  rabbits,  poisoned  with  diph- 
theria toxins  (tuberculosis,  typhus),  do  not  con- 
tain a  substance  which  either  raises  blood 
pressure  or  produces  enlargement  of  the  pupil." 

Biedl  himself  says  :    "  The  enormous  power 
which    suprarenal   extract   has   of    producing 


26     ESSAYS   ON   PRACTICAL    MEDICINE 

vaso-contraction  forms  the  rationale  of  its 
therapeutic  employment  in  all  those  conditions 
where  the  circulation  threatens  failure  in  con- 
sequence of  the  sluggishness  of  the  stream.  Of 
these,  the  most  comprehensive  are :  vascular 
paralysis,  such  as  may  be  produced  experi- 
mentally by  destruction  or  inhibition,  by 
means  of  toxins  (chloral  hydrate,  chloroform), 
of  the  vaso-motor  centres,  and  which  is  fre- 
quently seen  in  the  last  stages  of  some  in- 
fective diseases,  and  in  many  toxic  states ; 
and  cardiac  asthenia,  in  which,  owing  to 
inadequacy  of  the  heart  muscle  and  to  the 
vascular  paralysis,  those  symptoms  of  de- 
creased circulation  make  their  appearance 
which  are  known  as  '  shock '  or  '  collapse.' 
Paralysis  of  the  vessels  and  cardiac  weakness 
both  produce  a  fall  in  arterial  tension,  and 
lead  to  a  deficiency  in  the  blood  supply  to  the 
vital  nervous  centres,  as  well  as  to  an  insuffi- 
cient filling  of  the  chambers  of  th€  heart,  to 
cardiac  anaemia,  and  to  ultimate  arrest  of  the 
heart's  action.  By  producing  contraction  of 
the  engorged  vessels  in  the  splanchnic  area, 
and  so  raising  the  blood-pressure,  adrenalin 
effects  a  more  favourable  distribution  of 
blood  ;  it  promotes  the  filling  of  the  chambers 


DISORDERS   OF    THE   HEART  27 

of  the  heart,  and  increases  the  supply  of 
blood  to  the  nervous  system."  Later  on  he 
says :  "In  addition  to  its  effect  upon  the 
vessels,  adrenalin  exercises  a  tonic  effect  upon 
the  heart  muscle,  and  for  this  reason  its  exhi- 
bition is  indicated  in  all  forms  of  circulatory 
inadequacy."  Kothe's  dictum  "  that  adrena- 
lin is  the  most  powerful  analeptic  which  we 
possess  "  is  justified  by  clinical  experience. 

The  experiments  of  these  able  observers  and 
their  conclusions  should  lead  us  to  use  this 
remedy  far  more  than  we  at  present  do.  It 
is,  to  my  mind,  the  safest  and  most  powerful 
heart  tonic  that  we  have,  and  it  has  this  in 
its  favour,  that  it  is  a  natural  secretion  of  a 
mammalian  body.  My  experience  has  been 
for  the  last  few  years  that,  in  any  case  of 
heart  failure,  arising  in  the  course  of  some 
microbic  infective  disease,  and  where  the 
arterial  tension  is  below  the  normal,  supra- 
renal extract  is  a  wonderful  help.  In  pneu- 
monia, for  instance,  I  use  it  almost  from  the 
start,  but  I  make  the  arterial  tension  my 
guide.  For  use  by  the  mouth,  which  I  think 
gives  the  best  results,  the  extract  of  the  whole 
gland  should  be  given.  There  are  good  tablets, 
each  containing  five  grains  of  the  freshi  gland, 


28     ESSAYS    ON  PRACTICAL   MEDICINE 

on  the  market,  and  one  of  these  may  be  given 
every  four  hours  for  many  days  (i.e.  thirty 
grains  daily).  A  rise  of  tension  above  140"^- 
will  tell  one  when  to  stop.  Liquor  adrenalin 
given  by  the  mouth  seems  to  have  very  little 
lasting  effect  on  the  general  circulation. 

Oliver  and  Schafer's  original  experiments, 
from  which  so  much  valuable  knowledge  has 
been  derived,  were  made  with  a  strong  glycerine 
extract  of  the  whole  gland  given  by  the  mouth. 
I  beHeve  that  experience  will  prove  this 
remedy  to  be  of  the  utmost  value  in  the  stage 
of  acute  heart  failure  arising  from  infectious 
disease,  and  that  it  can  be  safely  used  when 
digitalis  and  strophanthus  would  do  harm. 
Unfortunately  we  are  more  often  called  in 
to  treat  the  results  only  of  these  acute  and 
damaging  diseases,  and  the  problem  then 
becomes  more  difficult  and  complicated.  In 
addition  to  valvular  defects  we  get  probably 
dilatation  or  hjrpertrophy,  or  both,  and  we 
must  be  careful  to  distinguish  and  to  measure 
the  two  conditions.  The  compensatory  hyper- 
trophy of  the  ventricles  is  often  sufficient  to 
keep  a  damaged  heart  going  for  a  long  time, 
with  very  few  symptoms  of  distress.  It  is 
when  this  hypertrophy  begins  to  fail  and  dila- 


DISORDERS   OF   THE   HEART  29 

tation  ensues  that  our  help  is  claimed.    This 
failure  of  power  may  have  come  on  gradually 
and   almost   imperceptibly,   or   suddenly.     In 
the  former  case  the  cause  may  be  an  unrecog- 
nised increase  of  bodily  effort,  or  insufficient 
rest,    or   it   may   be  weakening  of  the  heart 
muscle  by  some  intercurrent  illness,  as  influ- 
enza.    Again,    it   may   be   due   to    cicatricial 
contraction  of  the  damaged  valves  or  of  the 
chordae    tendinese.     A     careful    investigation 
and  a   correct  decision  will  help   one  much 
towards  giving  relief.    The  first  two  causes 
should  be  removable  by  rest  and  a  re-ordering 
of  the  patient's  life ;    the  third  will  probably 
require  some  medicinal  help  besides  mere  rest. 
If  there  is,  besides  dilatation,  shortness  of 
breath  and  irregularity  of  the  action  of  the 
heart,  with  or  without  a  tendency  to  dropsy, 
digitalis  should  be  given  in  doses  large  enough 
to  produce  physiological  effects  :   ten  or  fifteen 
minims  of  the  tincture  three  times  a  day,  and 
more  if  necessary.     If  the  liver  be  congested 
and  the  kidneys  acting  insufficiently  (in  such 
cases  the  urine  is  high-coloured,  scanty,  and 
of  high  specific  gravity),  the  pill  of  mercury, 
squills,  and  digitalis  may  be  given.     One  grain 
of  the  pulv.  digitalis  is  the  equivalent  of  about 


30     ESSAYS   ON   PRACTICAL   MEDICINE 

eight  minims  of  the  tincture  :  some  physicians 
give  calomel  instead  of  the  blue  pill  of  this 
combination,  and  in  cases  where  there  is  much 
constipation  it  is  an  improvement,  I  think 
probably  J  grain  three  times  a  day  would 
be  enough.  The  following  formula  is  gener- 
ally good  :  Ft.  pil.  t,d.s.  Pil.  Hydrarg.  g.  i ; 
Pulv.  Digitalis,  g.  i| ;  Pil.  Scillse  Co.,  g.  2. 
Where  there  is  high  arterial  tension  this  method 
of  giving  digitalis  is  especially  good,  as  the 
mercury  by  its  action  on  the  hver  tends  to 
keep  down  the  tension,  which  the  digitalis  by 
itself  might  raise.  This  should  produce  shortly 
a  stronger,  slower,  and  more  regular  pulse,  a 
freer  action  of  the  kidneys,  and  a  lessening  of 
dyspnoea ;  after  a  few  days,  unfortunately, 
with  many  patients  nausea  and  sickness  set 
in,  and  with  it  frequently  a  slow,  irregular 
pulse.  When  these  occur  digitalis  must  be 
left  off  for  a  few  days  and  then  resiuned  in 
smaller  doses. 

Another  plan  is  to  alternate  strophanthus 
and  digitalis.  To  get  the  best  result  in  such 
cases  from  strophanthus  full  doses  are  needed. 
There  has  seemed  to  me  to  be  a  considerable 
difference  in  the  value  of  various  preparations 
of  this  drug.     I  have  got  into   the  way   of 


DISORDERS   OF   THE   HEART  31 

ordering  either  Duncan  &  Flockhart's  special 
tincture  or  Burroughs  &  Wellcome's  tabloids, 
for  with  these  I  always  seem  to  get  good 
results. 

I  dislike  mentioning  special  drug  manu- 
facturers, but  the  above  firms  are  so  well 
known  that  nothing  I  say  can  benefit  or  harm 
them.  In  this  connection  I  may  mention 
Nativelle's  granules  of  digitalin  ;  the  stronger 
one  of  gr.  -^  is  very  useful,  and  perhaps 
causes  nausea  less  than  other  preparations 
of  digitalis.  (One  granule  =  n;  15  of  tincture.) 
After  a  short  time  of  such  treatment,  we 
should  be  able  to  form  a  fair  idea  of  the  heart's 
capabilities  towards  recovery.  The  physical 
signs  will  help  us  to  do  this,  but  we  must  rely 
a  good  deal  on  the  patient's  own  feelings.  An 
intelligent  patient,  when  being  treated  with 
these  special  heart  tonics,  knows  very  well 
whether  he  is  better  or  not — in  fact,  many  of 
them  can  be  trusted  to  manage  their  dosage 
and  continuance  of  digitalis  or  strophanthus 
for  themselves.  In  certain  cases  of  heart 
failure  with  dilatation,  especially  in  old  people, 
I  have  found  a  low  arterial  tension  ;  in  these, 
suprarenal  extract  in  alternation  with  digi- 
talin answers  very  well. 


32     ESSAYS   ON   PRACTICAL    MEDICINE 

Of  the  other  heart  tonics,  convallaria, 
spartein,  etc.,  I  have  nothing  to  say  ;  they 
seem  to  be  of  some  use  in  functional  disorders, 
but  their  sphere  of  action  is  not  well  defined. 

The  remaining  helps  to  a  tired,  failing  heart 
are,  well-planned  graduated  exercises,  and 
massage.  These  exercises  should  never  be 
pushed  to  the  point  of  exhaustion  or  of  breath- 
lessness.  They  comprise  various  exercises  of 
the  arms  and  legs  with  or  without  resistance, 
and  certain  body  movements.  These  are  in- 
cluded in  the  Swedish  and  Nauheim  systems. 
If  very  carefully  done  they  help  much  to 
restore  the  tone  of  the  heart  muscle. 

Dr.  Mackenzie  speaks  very  highly  of  sea- 
bathing. If  this  can  be  enjoyed  in  quiet 
water  that  is  not  too  cold,  it  is  certainly  in 
some  cases  a  great  stimulant  to  the  circulation 
(probably  quite  as  good  as  Nauheim  water), 
but  many  patients  seem  to  get  no  reaction 
and  to  remain  blue  and  cold.  These  cases  can 
hardly  benefit  by  sea-bathing.  The  exercise 
of  swimming  is  one  of  the  best,  in  fresh  or 
salt  water,  for  a  weak,  dilated  heart.  It  must, 
of  course,  be  done  slowly,  and  the  distances  be 
gradually  increased.  A  man  out  of  condition 
improves  his  wind  by  this  exercise  wonder- 


DISORDERS  OF   THE  HEART  33 

fully.    There  is  one  more  exercise,  which  is 
perhaps  the  best  of  all,  and  that  is  sculUng 
in  a  fairly  light  boat,  so  that  no  great  effort 
is  needed  ;    sculling  is  better  than  rowing,  for 
the  reason  that  it  exercises  slowly  and  sym- 
metrically almost  every  muscle  in  the  body 
(care  must  be  taken  that  the  patient  knows 
how  to  use  his  leg  niuscles  against  the  stretcher, 
otherwise  too  much  work  falls  to  the  arms  and 
the  heart  may  be  overstrained).    Most  of  these 
exercises  can  only  be  undertaken  by  the  milder 
cases  of  heart  weakness.     In  the  more  severe 
cases,  especially  where  signs  of  dropsy  have  | 
appeared,  steady  upward  massage  of  the  legs  j 
will  help  considerably.    Good  general  massage 
not  only  helps  to  get  rid  of  the  oedematous 
swelling,  but  improves  the  tone  and  the  pace 
of  the  circulation  all  over  the  body. 

By  using  these  various  remedies  intelli- 
gently and  with  careful  observation  one  may 
hope  to  see  many  a  failing  heart  restored  to 
comparative  health  and  usefulness. 

Dilatation  of  the  Heart  without  Manifest 
Valve  Disease 

In  middle  life  especially,  but  occasionally 
also  in  youth,  we  meet  with  cases  of  dilatation 

3 


34    ESSAYS  ON   PRACTICAL   MEDICINE 


of  the  heart  of  varying  degrees  of  severity, 
that   come  on  without   any  apparent  cause. 
(I  am  not  alluding  to  those  cases  that  are  the 
result  of  some  violent  and  prolonged  effort.) 
The  subjective  symptoms  are  generally  marked 
shortness  of  breath  on  any  exertion,  a  quick 
sometimes  irregular  pulse,  a  feeling  of  great 
fullness  in  the  chest,  and  areas  of  tenderness 
and  slight  pain  in  the  left  side  of  the  thorax 
and  sometimes  down  the  arms.    The  physical 
signs  I  need  not  describe.     Roughly,  a  heart 
dilates  for  one  of  two  reasons,  or  from  both  of 
them  combined.     First  from  some  resistance 
to  the  onward  easy  flow  of  arterial  blood  ;  this 
resistance  necessitates   an   increase   of   vis   a 
iergo,  of  ventricular  action,  and  this  increase, 
if  long  maintained,  may  cause  even  a  healthy 
heart  to  dilate,  though  probably  after  a  pre- 
liminary period  of  hypertrophy.    Apart  from 
valvular   obstruction,    arterio-sclerosis,    or   its 
earHer  stage  of  increased  tension  in  the  arteri- 
oles causing  peripheral  obstruction,  is  far  the 
most  common  cause.     Chronic  Bright 's  disease 
comes  almost  under  the  same  heading.     The 
other  cause  is  the  state  of  the  heart  muscle 
itself ;   it  is  generally  in  the  condition  known 
as  cloudy  sweUing  or  parenchjmiatous  degenera- 


DISORDERS  OF   THE  HEART  35 

tion.  This  often  follows  the  acute  fevers,  but 
is  especially  common  after  diphtheria  and 
influenza.  During  the  last  twenty-five  years 
in  which  influenza  has  been  so  much  among 
us,  these  cases  seem  to  have  been  far  more 
frequent.  In  this  state  of  heart  muscle,  a 
very  little  overstrain  will  produce  dilatation, 
even  where  there  is  no  peripheral  obstruction, 
either  valvular  or  arterial.  This  is  sometimes 
called  "  the  influenza  heart,"  the  normal  re- 
sistance being  too  great  for  the  enfeebled  heart 
muscle  to  cope  with. 

Far  more  commonly,  at  any  rate  in  middle 
life,  we  get  the  two  causes  working  simul- 
taneously, and  these  cases  require  very  careful 
and  patient  handling.  Here  the  manometer 
is  our  great  guide.  Unless  we  can  lower  the 
tension  and  lessen  the  peripheral  resistance, 
our  efforts  to  strengthen  the  ventricular,  beat 
and  to  produce  contraction  of  the  whole  organ 
may  do  more  harm  than  good.  Here,  I  think, 
strophanthus  is  superior  to  digitalis  as  a  heart 
tonic.  It  does  not  have  any  effect  on  the 
arterioles,  as  far  as  we  know,  and  it  can  be 
continued,  I  think,  for  much  longer  periods ; 
at  the  same  time,  by  attention  to  the  liver  and 
bowels  also,  we  can  help  to  keep  down  the 


36     ESSAYS   ON   PRACTICAL    MEDICINE 

tension.  The  nitrites  and  nitro-glycerine  may 
be  given,  but  their  effect  is  generally  too 
transient  to  be  of  much  help.  Erythrol  tetra- 
nitrate  seems  to  be  the  best  of  them.  An  occa- 
sional dose  of  blue  pill  or  calomel  is  of  much 
good.  Personally  I  rely  almost  entirely  on 
the  hippurates  in  these  cases  to  lower  the 
resistance.  I  shall  refer  to  these  more  fully 
in  another  essay,  and  also  to  the  contro- 
versy as  to  the  action  of  digitalis  in  high 
tension.  Thjnroid  extract  in  suitable  cases  is 
often  of  great  help  also. 

In  these  cases  when  the  dilatation  is  ex- 
treme, we  not  infrequently  get  regurgitant 
murmurs,  chiefly  mitral ;  these  will  disappear 
as  the  case  improves,  but  are  rather  confusing 
if  one  has  not  seen  the  patient  before.  The 
feeble  first  sound,  the  accentuated  second 
sound,  and  the  absence  of  the  heaving  systole 
against  the  chest  wall,  will  distinguish  the 
condition  from  that  of  hypertrophy.  The  wise 
and  intelligent  use  of  rest,  of  judicious  exercise, 
of  heart  tonics  combined  with  vaso-dilators, 
will  generally  give  in  the  end  very  satisfactory 
results,  unless  the  sclerosis  has  gone  too  far. 

The  dilatation  and  the  hsemic  murmur  that 
one  finds  in  anaemia  and  chlorosis  need  no 


DISORDERS   OF    THE   HEART  37 

special  mention ;  the  cure  of  the  anaemia  is 
the  cure  of  the  heart  trouble.  The  functional 
heart  troubles  and  their  manifold  causes  are 
too  large  a  subject  for  a  practical  essay  of  this 
kind.  Angina  pectoris  remains,  a  beautiful 
expression,  but  with  as  much  and  as  little 
meaning  in  it  as  "  stomach-ache."  It  may 
mean  the  most  serious  and  agonising  form  of 
heart  disease,  causing  death  very  soon,  or  it 
may  mean  nothing  but  a  mild  neuralgia.  The 
varied  and  uncertain  meanings  given  to  the 
term  are  most  unfortunate,  for  they  often  cause 
fear  and  anxiety  where  there  need  be  none, 
and  in  consequence  many  lives  are  rendered 
miserable  for  years.  If  no  strict  meaning 
clinically  or  pathologically  be  attached  to  this 
term,  the  expression  "  pseudo-angina "  be- 
comes equally  inaccurate  and  misleading. 

Mackenzie  says  :  '*  One  thing  that  is  neces- 
sary to  insist  on,  is  that  angina  pectoris  is  not 
a  disease ;  but  that  it  is  merely  a  group  of 
symptoms  which  afford  no  clue  as  to  the  real 
nature  of  the  heart's  complaint ;  so  that  in- 
quiry must  be  made  for  other  evidences  which 
will  elucidate  this  problem." 

The  organic  lesions  of  the  heart  with  which 
grave  anginal  symptoms  are  associated  are 


38     ESSAYS   ON   PRACTICAL    MEDICINE 

chiefly  aortic  valvular  disease,  aortic  aneurism, 
mitral  stenosis,  cardio-sclerosis,  general  athe- 
roma and  fatty  degeneration  of  the  heart 
muscle,  but  there  are  a  few  cases  in  which  no 
organic  disease  can  be  detected  by  physical 
examination.  The  atheroma  of  the  coronary 
arteries,  which  has  been  so  frequently  found 
after  death,  can,  when  existing  as  the  sole  cause, 
be  only  guessed  at.  All  these  conditions  may 
exist  and  yet  there  may  be  no  pain.  So  the 
solution  of  the  problem  lies  not  entirely  in  the 
heart  condition.  The  personal  history  of  most 
cases  shows,  as  a  cause  of  the  first  attack,  some 
extra  strain,  either  sudden  or  continued.  A 
man  of  forty-five  or  so  tries  to  do  something 
big  in  the  way  of  effort,  that  he  has  not  done 
for  some  years,  or  he  makes  some  exceptionally 
continuous  effort,  such  as  running  or  quick 
walking,  which  he  has  been  able  to  do  in  the 
past  without  discomfort.  Exposure  to  severe 
cold  is  also  reported  as  an  occasional  cause. 
The  sense  of  pain  may  be  sudden  and  severe, 
or  the  first  few  attacks  may  be  mild  and  short ; 
but  the  liability  to,  and  the  severity  of  this 
pain,  steadily  increase.  The  attacks  of  pain 
as  time  goes  on  may  need  little  or  no  effort  to 
bring  them  on. 


DISORDERS  OF   THE   HEART  39 

There  is  another  class  of  cases  which  I  can 
only  call  fulminating  angina,  in  which,  without 
any  previous  warning,  the  most  furious  attacks 
of  pain  come  on,  causing  the  patient  to  grasp 
hold  of  something  for  support  and  to  remain 
motionless,  scarcely  daring  to  breathe.     The 
face  gets  very  pale  and  the  forehead  breaks 
out  into  a  cold  sweat,  and  there  is  a  feeling  of 
great  constriction  over  the  whole  front  of  the 
thorax.    These  cases,  which  are  fortunately 
rare,  live  as  a  rule  but  a  short  time — death 
comes  suddenly  by  s5mcope  in  a  very  few  weeks. 
These  cases,  I  think,  arise  from  acute  degenera- 
tion of  the  myocardium,  and  generally  have 
disease  of  the  coronary  arteries.    They  are  not 
often  seen  as  the  end  of  valvular  disease,  and 
they  occur  in  middle  age,  generally  between 
forty-five  and  fifty-five,  and  the  condition  that 
causes  them  is  not  seldom  hereditary.    Not 
much  can  be  done  for  them  except  to  relieve 
the  spasm  by  amyl  nitrite  inhalation,  or  if  that 
fails  by  hypodermic  injection  of  morphia  and 
atropine. 

In  the  average  case  of  angina,  connected 
with  one  of  the  before-mentioned  causes, 
much  can  be  done  to  alleviate  and  to  prevent. 
The  ordering  of  the  life  so  as  to  avoid  hurry 


40     ESSAYS   ON  PRACTICAL   MEDICINE 

and  strain  must  be  the  first  thing.  If  the 
arterial  tension  be  high,  that  should  be  slowly 
and  carefully  reduced.  The  hippurates  may 
be  very  useful,  and  so  is  Lauder  Brunton's  plan 
of  giving  a  good  dose  of  20  grains  of  nitrate 
of  potash  combined  with  two  grains  of  sod. 
nitrite  every  morning  before  breakfast.  The 
amyl  nitrite  or  nitro-glycerine  will  be  very 
helpful  in  the  attack,  or  the  following,  which 
I  have  found  very  useful : 

B.  Spt.  Ether  Sulph.  Co.       .         .         .     HI.  20 
Liq.  Trinitrin  .  .  .  •     ^     i  i 

Tinct.  Chloroform  Co,  (sine  Morph.)         n\  12 
Spt.  Ammon.  Aromat,  ad  ,         .      3     ^ 

3i  in  half  a  wineglass  of  water  for  a  dose. 

But  the  remedy  that  in  most  cases  will  do 
more  good  than  any  of  the  above  is  iodide  of 
potassium  in  doses  of  10  grains  or  more  three 
times  a  day ;  if  given  with  elixir  of  lactoj 
peptine  and  spirits  of  chloroform,  it  will 
generally  digest  well  and  not  cause  iodism. 
An  anomaly  difficult  to  explain,  but  generally 
true,  is  this.  The  greater  the  dose  of  the 
iodide,  the  less  is  the  fear  of  iodism.  It  is 
more  than  Hkely  that  iodide  works  by  stimu- 
lation of  th5n:oid  secretion,  but  this  will  be 
mentioned  in  another  chapter.    It  is  perhaps 


DISORDERS  OF   THE  HEART  41 

in  the  aortic  and  atheromatous  cases  that  it 
answers  best.  I  do  not  think  it  acts  by  any 
distinct  lowering  of  arterial  tension,  though 
some  physicians  say  that  it  has  that  effect. 
It  should  be  continued  for  a  long  time,  and  will 
often  give  the  most  satisfactory  results. 

Indigestion  which  causes  flatulence,  disten- 
sion of  the  stomach,  and  hyperacidity  are  both 
exciting  causes  of  this  pain.  When  once  the 
disease  is  established,  the  diet  should  be  care- 
fully arranged  to  obviate  these  discomforts  as 
far  as  possible.  A  comparatively  dry  diet, 
with  no  excess  of  starchy  food,  should  be  the 
central  idea,  fluid  being  taken  between  meals. 
An  intelhgent  patient,  if  shown  the  reasons, 
will  probably  work  out  a  diet  for  himself. 
Twice-cooked  animal  and  fish  food  seems  to  be 
a  very  common  cause  of  flatulence  with  many. 
But  the  great  question  to  solve  is  the  cause 
of  the  pain.  Under  apparently  identical  con- 
ditions, one  man  gets  angina  and  another  does 
not.  In  some  cases  there  is  raised  arterial 
tension  and  peripheral  resistance,  in  some  the 
tension  may  be  below  normal,  but  I  think  in 
the  majority  of  cases  the  tension  is  raised.  As 
far  as  one  can  judge  the  pain  comes  on  because 
the  heart  is  suddenly  called  on  to  make  a, 


42     ESSAYS   ON   PRACTICAL   MEDICINE 

muscular  effort  which,  owing  to  obstruction  or 
to  some  faulty  condition  of  the  muscle  itself, 
it  cannot  accomplish.  A  painful  condition  of 
cramp  or  spasm  is  produced,  beginning  prob- 
ably in  the  heart  and  spreading  to  the  inter- 
costal muscles  and  perhaps  to  the  diaphragm. 
It  is  easy  to  understand  how  a  severe  cramp 
in  the  heart  muscle  becomes  a  great  danger, 
while  a  cramp  in  a  leg  muscle  is  of  no  con- 
sequence, for  the  circulation  must  be  tem- 
porarily arrested,  and  if  the  cramp  does  not 
pass  off,  death  may  ensue  in  the  attack. 

The  seat  of  obstruction  may  be  valvular, 
arterial,  or  in  the  coronary  arteries  of  the 
heart  itself,  and  in  the  latter  case  there  seems 
to  be  greater  danger,  because  the  blood  supply 
to  the  heart  muscle  is  itself  partially  cut  off. 
Still  the  question  of  the  cause  of  the  pain  is 
only  partially  solved.  How  far  the  nervous 
system  enters  into  the  problem  is  the  doubt. 

Mackenzie  says  :  "  Pain  is  usually  referred 
to  some  portion  of  the  distribution  of  the  upper 
four  left  dorsal  nerves  in  the  chest  and  arm  ; 
sometimes  the  pain  may  be  felt  as  low  as  the 
distribution  of  the  sixth  dorsal  nerve  in  the 
epigastriiun,  and  as  high  as  the  eighth  or 
seventh  cervical  nerve  in  the  ulnar  border  of 


DISORDERS   OF   THE   HEART  43 

the  forearm  and  hand.  It  is  rarely  felt  in 
similar  areas  on  the  right  side.  The  pain  is 
usually  felt  across  the  chest,  and  may  remain 
stationary  there ;  or  it  may  radiate  into  the 
axilla  and  down  the  arm  to  the  ulnar  side  of 
the  forearm  and  hand.  On  the  other  hand  the 
pain  may  start  in  the  arm  and  radiate  to  the 
chest." 

These  clear  statements  point  to  some  centres 
in  the  dorsal  part  of  the  spinal  cord  being  con- 
cerned, not  as  organically  diseased,  but  as  in 
a  state  of  irritability.  Some  of  the  nervous 
s5niiptoms  that  are  usual  after  an  attack,  such 
as  the  passage  of  a  large  quantity  of  colourless 
urine  and  the  free  expulsion  of  wind,  point  the 
same  way.  In  fact,  it  seems  that  in  a  pre- 
disposed heart  the  trouble  may  arise  at  the 
centre  as  well  as  the  periphery.  We  must 
hope  that  further  skilled  investigation  will 
throw  more  light  on  this  problem  and  help  us 
more  to  ward  off  attacks  and  to  treat  them 
more  successfully  than  we  do  now.  So  far  as 
our  knowledge  goes  at  present  we  can  only 
advise  our  patients  who  suffer  from  cardiac 
pain  that  threatens  to  be  angina,  always  to 
have  with  them  capsules  of  amyl  nitrite  or 
tablets  of  nitro-glycerine,    Sir  William  Whitia 


44     ESSAYS   ON   PRACTICAL   MEDICINE 

advises  patients  who  suffer  froin  frequent 
attacks  of  cardiac  pain  to  break  up  one  of 
the  usual  tablets  of  nitro-glycerine  into  six  or 
eight  parts,  and  to  take  one  of  the  fragments 
every  hour  or  so  during  the  day.  I  have  found 
this  plan  in  my  own  practice  very  useful. 
Though  one  objects  to  the  word  "  pseudo- 
angina/'  yet  one  must  recognise  that  there  is  a 
class  of  person  who  gets  cardiac  pain  that  bears 
some  resemblance  to  the  true  thing  ;  but  there 
are  pretty  marked  signs  of  differentiation. 
Such  patients  are  generally  women,  about  the 
age  of  fifty,  who  get  other  symptoms  of  vaso- 
motor disturbance.  The  arterial  tension  is 
often  high,  but  it  varies  much  at  different 
times.  I  think  that  nearly  every  woman, 
about  or  after  the  change  of  life,  gets  periods 
of  high  tension,  and  that  nature  gives  relief 
by  the  flushings  and  perspirations  that  are  so 
common.  The  flushing  has  the  same  effect 
as  amyl  nitrite.  In  such  cases  there  is  no 
evidence  of  any  organic  disease,  and  there 
may  be  a  history  of  excessive  tea-drinking  or  of 
tobacco-smoking.  The  most  important  sign  is 
I  think,  the  behaviour  when  the  pain  is  on. 
The  true  angina  sufferer  remains  as  still  and 
quiet  as  possible,  almost  afraid  to  breathe  or 


DISORDERS   OF   THE   HEART  45 

speak ;    the  false  one  fidgets  about  in  a  rest- 
less, excited  way.     Careful  examination  and 
observation  will  in  most  cases  enable  us  to 
assure  such  patients  that  there  is  no  danger, 
and  attention   to   the   arterial  and   nervous 
conditions  should  soon  effect  a  cure.     In  the 
advanced  stage  of  almost  any  form  of  heart 
disease,  except,  perhaps,  in  true  angina,  we 
shall  meet  with  emergency  cases  that  look  like 
impending  death.   Such  are  cases  of  acute  dila- 
tation, of  sudden  pulmonary  oedema,  sometimes 
called  suffocative  oedema,  and  of  advanced 
auricular  fibrillation.    Here  we  have  to  act  at 
once,  and,  valuable  as  digitalis  is  in  nearly  all 
these  troubles,  yet  there  is  no  time  for  it  to 
act  when  given  by  the  mouth.     (The  hypo- 
dermic use  of  digitalin   is  generally  futile.) 
We  have,  however,  a   very  rapid  and  safe 
remedy  in  the  hypodermic  injection  of  adrena- 
lin ;   and  the  action  is,  I  think,  much  helped 
if  we  give  with  it  liq.  trinitrin.    The  best  way 
of  giving  this  is  the  following  :    8  minims  of 
liq.  adrenalin,  2  minims  of  liq.  trinitrin,  and  fill 
up  the  syringe  with  water  {boiled  if  you  have 
time  to  get  it)  to  20  or  30  minims.    The  liq. 
adrenalin  is  too  concentrated  a  preparation 
for  most  people.     It  not  infrequently  brings 


46     ESSAYS   ON   PRACTICAL   MEDICINE 

on  pallor  and  a  feeling  of  faintness  for  a  few 
minutes.  This  is  obviated  by  dilution.  Many 
of  these  patients  may  have  a  high  arterial 
tension,  but  this  need  not  deter  one,  for  adre- 
nalin has  none  of  its  characteristic  action  on 
the  coronary  arteries,  and  the  trinitrin  helps 
its  effect  by  lowering  the  tension  in  the  sys- 
temic arterioles.  Briefly  put,  the  nitrites 
dilate  the  coronary  veins  as  well  as  other 
systemic  veins.  The  adrenalin  dilates  the 
coronary  arteries  and  increases  the  contrac- 
tion of  muscular  fibres,  in  heart,  arteries 
and  arterioles.  The  laboratory  researches  on 
adrenalin  vaso-motor  mechanisms  by  Dr.  Hart- 
mann  of  Toronto  {"  Endocrinology,"  vol.  ii., 
no.  i)  go  far  to  explain  and  to  direct  the  thera- 
peutic action  of  adrenaUn.  He  shows  that  vaso- 
dilatation is  the  usual  response,  in  certain 
areas  of  the  body,  to  adrenalin  injections.  He 
says,  in  the  adult,  adrenalin  poured  into  the 
blood  in  small  quantities  causes,  by  its  peripheral 
effects,  constriction  of  the  vessels  in  the  skin, 
mucous  membrane  and  abdominal  organs, 
driving  the  blood  into  the  vessels  supplying  the 
skeletal  muscles,  which  are  actively  dilated  for 
its  reception,  through  the  effect  on  the  sym- 
pathetic and  dorsal  root  gangliar  mechanisms. 


DISORDERS   OF    THE   HEART  47 

This  increase  of  blood   supply  to  the   limbs 
is  proved  by  plethysmographic  tracings.     One 
can  now  understand  the  relief,  very  great  in 
some  cases  of  dyspnoea,  cardiac  and  asthmatic, 
that  adrenalin  gives.    The  patient  is  bled  liter- 
ally into  his  own  far-distant  vessels,  which  can 
accommodate  the  extra  blood  without  distress  ; 
the  congestion  of  the  heart  and  lung  regions  is 
thereby  relieved.     When  the  trinitrin  is  added 
to  the  adrenalin,  a  still  further  relief  is  obtained 
by  the  dilatation  of  the  blood-vessels  of  the 
head  and  neck.     Hypodermically,   strychnine 
may  be  used  to  follow  the  adrenalin,  but  it 
is  of  no  value   except  in  full  doses — xV  to 
yV  gr.     By  these  means  many  an  emergency 
can  be  tided  over  and  the  opportunity  for  the 
steady  use   of   digitalis  or   strophanthus  be 
established. 

Another  most  distressing  trouble  that  we 
often  meet  with  in  the  advanced  stages  of 
heart  failure  is  the  inability  to  get  any  con- 
tinuous sleep.  One  cannot  call  it  insomnia,  for 
the  desire  to  sleep  is  very  strong  ;  the  patient 
keeps  dropping  off  and  waking  up  again  in  a 
few  minutes,  often  in  great  respiratory  distress. 
Narcotics  given  by  the  mouth  are  of  very 
little  good,  with  the  occasional  exception  of 


48     ESSAYS  ON  PRACTICAL   MEDICINE 

paraldehyd.     The  one  great  help  in  these  cases 
is  the  hypodermic  use  of  morphia  and  atropine 
or  of  morphia  and  scopalamine  ;   one  or  other 
combination   is   better   than   morphia   alone. 
If  there  be  no  great  clogging  of  the  lungs  by 
oedema,  or  by  bronchial  catarrh,  it  may  be 
used  with  confidence,  both  as  regards  success 
and  safety.     The  hours  of  sound  sleep  that 
ensue   rest,   not   only   the   patient,   but   the 
patient's  worn-out,  irritated  heart.     If  there 
be  inaction  of  the  kidneys  as  a  result,  a  hypo- 
dermic injection  of  pituitrin  in  the  morning 
will  probably  put  things  right. 

Though  this  essay  has  gone  over  much  that 
is  old  ground,  and  contains  little  that  is  new, 
I  venture  to  hope  that  it  may  serve  to  concen- 
trate some  of  the  more  modern  knowledge  of 
heart  affections  into  more  practical  and  useful 
methods  of  management  and  of  therapeutics. 


II 

ARTERIO-SCLEROSIS 

"  Wherefore  do  ye  spend  money  for  that  which  is  not 
bread,  and  your  labour  for  that  which  satisfieth  not  ?  " 

Isaiah. 

When  one  carefully  studies  the  diseased  con- 
dition we  call  arterio-sclerosis  or  fibrosis,  as 
Sir  William  Gull,  its  first  describer,  called  it, 
its  complications,  its  results,  and  some  other 
disorders  with  which  it  is  intimately  associated, 
one  must  see  that  it  enters  very  largely  into 
the  failures  of  health  and  into  the  premature 
deaths  that  occur  so  frequently  between  the 
ages  of  forty-five  and  sixty. 

Dr.  De  Havilland  Hall,  who  is  an  authority 
on  this  disease  and  also  on  its  life-insurance 
aspects  and  its  statistics,  says  "  that,  though 
the  average  duration  of  life  has  considerably 
increased  during  the  last  fifty  years,  there  has 
been  an  actual  increase  in  the  mortahty  rate 
among  males  between  the  ages  of  forty-five 
4  49 


50     ESSAYS  ON  PRACTICAL   MEDICINE 

and  sixty-five,  and  that  between  the  ages  of 
fifty-five  and  sixty-five  one-third  of  the  total 
deaths  are  due  to  diseases  of  the  heart  and 
blood-vessels. "  These  statistics  are  obtained 
from  the  Registrar-General's  reports,  and,  as 
far  as  they  go,  must  be  accurate.  My  own 
feeling  is  that  a  good  many  more  deaths  could 
be  brought  under  the  same  categories,  for 
many  deaths  from  paralysis  and  cerebral 
haemorrhage  are  returned  under  those  headings, 
but  are  really  the  end  results  of  arterio-sclerosis. 
To  the  general  practitioner  it  is  a  very 
important  thing  to  keep  his  patients,  who  are 
approaching  old  age,  in  good  health,  and  to 
prolong  their  lives  as  far  as  possible.  It  should 
not  only  be  his  interest  to  do  this,  but  also  his 
deHght,  for  one's  old  patients  are  often  one's 
best  friends.  Too  many  of  us  have  got  into  the 
way  of  looking  on  this  disease  as  incurable 
and  unmanageable,  but  this  is  a  great  mistake. 
It  is  a  complicated  and  intricate  problem,  no 
doubt,  but  that  should  attract  the  scientific 
mind  to  the  elucidation  of  the  problem  and 
to  the  study  of  the  causes  and  the  treatment. 
Strictly  speaking,  arterio-sclerosis  is  not  an 
entity  disease,  like  tuberculosis  or  cancer.  It  is 
in  most  cases  a  structural  change  due  to  un- 


A  RTERIO'SCLEROSIS  51 

natural  causes  that  are  not  obscure  and  which 
to  a  large  extent  are  removable.  I  think  we 
must  all  feel  that  the  causes  lie  deep  in  our  ways 
and  habits,  in  the  unnatural,  high-pressure 
lives  that  so  many  of  us  seem  compelled  nowa- 
days to  live,  and  in  the  fact  that  this  increase 
of  heart  and  vascular  disease  occurs  in  the  male 
sex  so  much  more  than  in  the  female.  The 
competition  of  business  and  professional  life 
falls  almost  entirely  on  our  sex,  but  when  we 
come  into  touch  with  the  arduous,  nerve- 
straining  life  that  many  society  women  live, 
the  late  hours  and  the  over-stimulation  of 
various  sorts  that  it  seems  to  involve,  we  see 
the  same  morbid  results  in  their  train.  It 
is  not  the  hard  body  worker,  not  the  man  who 
live  an  outdoor,  athletic  life,  that  develops 
sclerosis,  as  a  rule,  but  the  anxious,  care- 
worn brain  worker,  who  works  chiefly  indoors 
and  who  often  takes  his  work  and  his  worries 
home  with  him  and  to  bed  with  him.  For 
such  a  man  there  can  seldom  be  any  real 
rest  or  freedom  from  the  sense  of  strain.  His 
sleep  is  rarely  the  sound,  restoring  uncon- 
sciousness that  the  body  worker  gets ;  and  in 
very  many  cases  the  ability  to  meet  this  nerve 
strain  is  artificially  kept  up  by  stimulants  of 


52     ESSAYS  ON   PRACTICAL   MEDICINE 

various  sorts,  but  their  effect  can  only  act  for 
a  time.  The  physiological  result  of  this  life 
must  be,  in  the  first  place,  fatigue,  exhaustion 
and  general  impairment  of  vital  energy,  but  in 
the  second  place  hypertrophy  and  subsequent 
degeneration  of  the  over-used  parts  of  the  body 
(this  is  a  law  from  which  we  cannot  escape), 
and  the  over-used  parts  are  chiefly  the  heart 
and  blood-vessels.  The  athlete  may  call  on 
his  heart  to  do  much  abnormal  work,  but  it  is 
only  for  a  short  time,  and  the  intervals  of  rest 
are  long  and  sufficient  for  restoration  ;  but  the 
man  I  am  describing  is  the  bow  always  bent. 
The  activity  of  his  brain  is  making  demands 
on  his  heart  and  on  his  arteries  night  and  day, 
and  the  vaso-motor  nerves  that  govern  the 
blood  supply  to  the  cerebral  centres  have  no 
rest  from  toil. 

Dr.  George  Oliver  very  wisely  says  :  "  Ner- 
vous, anxious  temperaments,  and  occupations 
which  involve  much  anxiety,  worry  and  nerve 
strain,  tend  to  produce  somewhat  higher  levels 
of  arterial  pressure,  especially  in  the  latter  half 
of  life.  On  the  other  hand,  placid  tempera- 
ments and  routine  occupations — especially  of 
the  physical  order — dispose  to  the  lower  degrees 
of  pressure.     I  have  observed  that,  as  a  rule. 


ARTERIOSCLEROSIS  53 

in  subjects  in  good  condition  and  training — 
such  as  athletes — the  arterial  pressure  is  cer- 
tainly not  raised,  and  is  indeed  very  often 
somewhat  below  the  average  normal  point,  a 
fact  which  shows  the  importance  of  maintain- 
ing the  functional  activity  of  the  peripheral 
circulation  by  exercise.  And  this  conclusion  is 
supported  by  the  observation  that  in  those 
normal  subjects  who  follow  sedentary  indoor 
occupations  for  many  hours  daily,  the  pressure, 
though  generally  normal,  is  more  frequently 
above  and  less  frequently  below  the  mean 
normal  pressure  line." 

There  can  be  no  doubt,  I  think,  that  there 
is  a  stage — -probably  lasting  for  two  or  three 
years — of  almost  constantly  but  moderately 
raised  tension,  before  any  real  sclerosis  takes 
place  ;  and  it  is  in  this  stage  that  we  can  do 
so  much  for  our  patients,  to  correct  their  habits 
of  life  and  so  to  avert  the  grave  symptoms 
that  otherwise  must  ensue.  Dr.  Oliver  says  on 
this  point :  "In  diffuse  or  generalised  arterio- 
sclerosis, the  accessible  arteries  may  not  be 
appreciably  thickened,  especially  in  the  earlier 
stages  of  the  disease,  and  yet  the  arterial  pres- 
sure may  be  raised  persistently  and  definitely. 
It  would  seem  as  if  the  disease  begins  more 


54     ESSAYS  ON  PRACTICAL   MEDICINE 

particularly  in  the  terminal  divisions  of  the 
arterial  system — splanchnic  and  systemic,  es- 
pecially splanchnic.  In  this  stage  the  peri- 
pheral resistance  is  apparently  due  mainly  to 
muscular  contraction  in  the  arterioles  ;  for 
these  readily  respond  to  vaso-dilator  remedies, 
and  the  increment  of  arterial  pressure,  which 
is  not  so  high  as  it  subsequently  becomes, 
quickly  subsides  after  each  dose.  In  this 
hypertonic  stage,  the  stage  of  pre-sclerosis  of 
Houchard,  the  diastolic  pressure  rarely  rises 
above  120  mm.  and  is  often  only  no  mm.,  and 
the  systoHc  pressure  does  not,  as  a  rule,  exceed 
160  mm.  and  is  frequently  only  145  mm.  or 
150  mm.,  and  the  arteriometer  demonstrates 
the  contraction  of  the  radial  caHbre  and  the 
favourable  effect  of  treatment  in  dilating  it. 
But  as  the  disease  advances,  organic  changes 
in  the  arterial  wall  develop,  when  vaso-dilators 
only  partially  reheve  the  pressure,  and  when 
they  may  ultimately  fail  to  lower  it.  In 
this  stage  the  accessible  arteries — such  as  the 
brachial — as  a  rule  become  thickened  and  the 
arterial  pressure  increases  considerably  ;  the 
systolic  armlet  readings  advancing  to  such  high 
figures  as  200  mm.  to  260  mm/' 
Another  cause  of  hypertension  and  subsequent 


ARTERIOSCLEROSIS  55 

sclerosis,  which  often  goes  hand  in  hand  with 
the  "strain  of  Hf e  "  and  its  results,  is  intes- 
tinal poisoning  or  auto-intoxication.  Owing  to 
various  reasons,  excess  of  food,  improper  food, 
lack  of  proper  resting  time  for  digestion,  and 
alcholic  or  other  stimulation,  there  is  set  up 
a  chronic  dyspepsia,  gastric  and  intestinal, 
which  leads  to  more  or  less  constant  absorption 
of  ptomaines.  These  affect  the  liver  and  its 
healthy  secretion  of  bile,  and  so  a  vicious  circle 
is  set  up ;  they  also  affect  the  endocrine  glands, 
especially  perhaps  the  thyroid  and  the  supra- 
renal, and  through  them  the  vaso-motor  system; 
and  finally  some  of  the  excretory  organs,  espe- 
cially the  kidneys,  which  have  an  extra  load 
thrown  on  them,  a  load  which  they  can  only 
carry  for  a  time  without  injury. 

This  intestinal  absorption  of  ptomaines  de- 
mands very  serious  attention,  for  it  is  always 
frustrating  one's  efforts  to  lower  pressure.  If 
the  diet  and  life  can  be  wisely  regulated,  it 
can  soon  be  put  right.  The  chief  remedy  should 
be  occasional  doses  of  calomel,  in  antiseptic, 
not  in  aperient  doses  (for  we  want  chiefly  to 
get  its  bactericidal  action).  Mercury  in  all 
forms  seems  to  lower  blood-pressure,  but 
whether  directly  or  indirectly  is  not  easy  to 


56     ESSAYS  ON  PRACTICAL   MEDICINE 

say.  The  frequent  use  of  duodenal  extract 
in  some  form  is  very  beneficial  also  ;  this  is  a 
natural  remedy,  and  is  very  effective  :  2  grains 
of  duodenal  extract  in  a  pill  three  or  four  times 
a  day  about  an  hour  after  food,  combined,  if 
there  be  gastric  dyspepsia,  with  half  a  grain 
of  carbolic  acid,  will  soon  give  great  relief  and 
purify  the  intestine.  Secretogen  tablets  act 
very  well  on  the  same  lines. 

As  practical  physicians,  then,  our  aim  must 
be  to  get  hold  of  our  patients  in  this  pre- 
sclerotic  condition,  to  wisely  anticipate  and 
prevent  the  development  of  the  serious  organic 
changes  that  belong  to  the  later  stages.  To 
do  this  we  must  be  on  the  look-out,  especially 
at  about  the  ages  of  forty-five  to  fifty-five,  for 
any  sUght  but  persistent  increase  of  arterial 
tension.  There  are  various  subjective  symp- 
toms that  are  often  danger  signals  :  viz., 
slightly  increased  shortness  of  breath  on  exer- 
tion, laboured  action  of  the  heart  or  slight 
palpitation ;  but  perhaps  of  more  significance 
are  the  head  symptoms,  such  as  vertigo, 
especially  on  stooping,  occasional  noises  in  the 
head,  and  an  unaccustomed  feeling  of  brain 
fatigue  without  any  sufficient  cause.  At  this 
stage   there   is,   as   a   rule,   no   albuminuria. 


ARTERIOSCLEROSIS  57 

but  the  kidney  condition  should  be  carefully 
watched. 

In  the  earlier  days  of  the  study  of  sclerosis, 
the  kidneys  were  always  regarded  as  the  chief 
danger-point.  My  old  friend,  whose  prema- 
ture death  was  such  a  loss.  Dr.  Mahomed 
of  Guy's,  called  it  pre-albuminuric  disease, 
but  there  are  a  large  number  of  cases  in  which 
the  kidneys  never  become  seriously  affected  ; 
the  brunt  of  the  disease  falls  in  some  cases  on 
the  heart,  the  larger  arteries  and  the  coron- 
aries  ;  in  some  on  the  cerebral  arteries  ;  and  in 
others  on  the  kidneys.  The  whole  of  the  organs 
may  be  involved,  but  the  symptoms  of  course 
vary  with  the  functions  of  the  parts  affected. 
In  any  case  death  comes  more  frequently  from 
the  rupture  of  cerebral  arteries  than  from 
heart  and  kidney  failure. 

To  form  a  clear  and  accurate  idea  as  to 
the  arterial  condition  and  pathology  and  as  to 
the  relative  importance  of  abnormalities,  one 
must  make  a  careful  study  of  the  literature  of 
this  subject,  and  this  will  not  take  very  long, 
I  would  mention  two  small  and  inexpensive 
books,  whose  authorship  is  their  own  guaran- 
tee :  "  Studies  in  Blood- Pressure,''  by  Dr. 
George  Oliver  (H.  K.  Lewis)  ;    and  "  Thera- 


58     ESSAYS  ON   PRACTICAL   MEDICINE 

peutics  of  the  Circulation,"  by  Lauder  Brunton 
(John  Murray).  If  a  more  elaborate  work  is 
wished  for  and  one  that  goes  deeply  into  the 
physics  of  the  circulation,  Sir  Clifford  Allbutt's 
most  excellent  book  on  "  Diseases  of  the 
Arteries ' '  will  give  us  all  we  need.  From  these 
clear  and  most  rehable  books  the  busy  practi- 
tioner will  soon  get  a  good  working  idea  of  the 
subject.  The  estimation  and  significance  of 
systolic  and  diastoHc  blood-pressure  and  the 
use  of  the  manometer  and  sphygmograph  are 
all  carefully  explained.  I  need  hardly  say  that 
the  use  of  the  manometer  in  arterio-sclerosis 
amounts  to  a  sine  qua  non. 

The  hypertonic  stage  of  muscular  contrac- 
tion, described  above  by  Dr.  OHver,  is  prob- 
ably the  direct  outcome  of  the  over-strenuous 
life,  and  should  be  regarded  as  only  a  func- 
tional disturbance  and  therefore  remediable. 
It  is,  of  course,  in  this  stage  that  we  can  really 
cure ;  in  the  later  stages  very  much  can  be 
done  to  guide  and  alleviate,  but  not  to  cure. 

To  get  fixed  in  our  minds  a  clear  idea  of 
the  physiology  of  the  arterial  system,  I  cannot 
do  better  than  quote  from  Lauder  Brimton, 
Lancet,  vii.  24.  15:  '*  The  whole  of  the 
arterial  system  from  the  aorta  down  to  the 


ARTERIOSCLEROSIS  59 

smallest  arterioles  has  the  power  of  contrac- 
tion, but  there  is  much  more  elasticity  and 
less  contractibility  in  the  aorta  than  in  the 
arterioles,  where  the  contractibility  is  great 
and  the  elasticity  comparatively  sHght.  The 
whole  system  is  richly  supplied  with  nerves, 
some  of  which,  the  vaso-motor  nerves,  induce 
contraction,  while  others,  the  vaso-dilators, 
have  an  opposite  effect.  The  arteries  have 
three  functions.  First,  by  means  of  their 
elasticity  to  store  up  the  energy  exerted  by  the 
left  ventricle  during  its  systole,  and  to  expand 
this  again  in  keeping  up  the  even  flow  of 
blood  during  the  diastole,  when,  in  the  healthy 
heart,  the  ventricle  is  completely  shut  off  from 
the  aorta  by  the  sigmoid  valves.  The  second 
function  is  to  regulate  the  flow  of  blood  to 
those  parts  which  need  it,  by  those  vessels 
which  supply  the  active  organs  dilating,  while 
those  of  the  other  parts  of  the  body  contract. 
The  third  function,  which  is  less  generally 
recognised,  is  to  pass  the  blood  on  from  the 
arteries  into  the  veins  by  peristaltic  action,  an 
action  which  causes  the  arteries  to  be  empty 
after  death." 

Arterial  tension  may  be  briefly  described 
thus :    during  the  resting-time  of  the  heart. 


6o    ESSAYS  ON  PRACTICAL   MEDICINE 

between  each  beat,  the  ckculation  of  the 
blood  is  maintained  by  the  contractile  power 
of  the  arteries,  especially  by  that  of  the 
arterioles,  which  steadily  urges  the  blood 
onwards  into  the  capillaries  ;  this  power  is 
known  as  arterial  tension  or  pressure,  and  can 
be  estimated  fairly  accurately  by  the  sphygmo- 
manometer. A  large  number  of  observations 
have  shown  what  is  the  average  pressure 
at  different  ages,  and  we  are  thus  able  to 
talk  of  a  normal  or  abnormal  pressure  or 
tension. 

The  following  extract  from  the  Lancet, 
January  8,  1916,  puts  the  matter  in  a  most 
conclusive  way  : 

**  The  clinical  value  of  observations  on  blood- 
pressure  is  doubted  only  by  those  who  have 
never  made  them.  It  is  true  that  the  finger 
can  detect  some  difference  in  pulse  tension, 
but  it  is  often  entirely  at  fault,  since  it  can 
only  estimate  total  pressure,  thus  missing  a  high 
pressure  if  the  volume  be  small.  In  the  same 
way,  although  the  hand  can  detect  differences 
of  temperature,  it  cannot  replace  the  thermo- 
meter. The  sphygmomanometer  has  enlarged 
our  ideas,  cleared  up  difficulties  in  diagnosis, 
and  helped  in  prognosis. 


ARTERIOSCLEROSIS  6l 

*  *  This  has  naturally  reacted  on  treatment ;  it 
has  enlarged  our  ideas  on  '  heart  failure.'  The 
heart  is  adjusted  to  work  at  certain  pressures, 
and  though  within  considerable  limits  it  can 
adjust  itself  to  variations,  those  limits  may  be 
exceeded. 

"  In  an  acute  infection  blood- pressure  may 
fall  dangerously  low,  and  sensory  stimuli  do 
not  produce  the  usual  pressor  result,  though 
abdominal  massage  is  still  effective.     It  is  the 
vaso-motor  system  that  is  poisoned,  rather  than 
the  heart  that  is  damaged.     Recognition  of 
these  facts  has  led  to  the  problem  being  attacked 
through  the  vaso-motor  system  by  means  which 
act  peripherally,  thus  protecting  the  heart  from 
secondary  damage  and  needless  or  harmful 
stimulation.     There  is  the  opposite  condition 
in  which  the  heart  fails,  while  the  pressure  is 
very  high.     In  some  cases  where  the  pressure 
has  been  unduly  high,  perhaps  for  years,  the 
heart  fails  because  it  can  no  longer  work  against 
an  excessive  resistance.     But  in  others  it  is 
probable  that  the  rise  of  pressure  is  compensa- 
tory.    With  diminishing  output  vaso- constric- 
tion is  necessary  to  lessen  the  size  of  the  arterial 
bed.     But  this   vaso-constriction  would  only 
raise  the  blood-pressure  to  its  normal  level 


62     ESS  AY  SI  ON  PRACTICAL   MEDICINE 

again  ;  it  would  not  force  it  higher.  Yet  it  is 
often  a  surprise  to  find  with  a  feebly  beating 
heart  a  pressure  of  200  mm.  or  more.  The 
recent  work  of  StarUng  throws  fresh  light  on 
this  apparent  paradox.  The  contractile  force 
of  a  muscle  depends  upon  and  is  proportional 
to  its  previous  stretching,  so  that  in  its  inception 
even  cardiac  dilatation  is  compensatory,  and 
a  rise  of  blood-pressure  will  increase  the  stretch- 
ing of  the  cardiac  muscle.  But  it  is  a  desperate 
expedient,  for  with  over- stretching  complete 
failure  may  ensue." 

Writing  ten  years  later  than  the  foregoing 
extract,  I  grieve  to  say  that  I  still  find  doctors 
attempting  to  estimate  blood-pressure  by  their 
finger,  and  to  found  their  treatment  on  that 
estimate.  I  can  only  say  that  the  results  are 
equally  disastrous  to  their  patients  and  to  the 
reputation  of  their  profession. 

The  left  ventricle  is  of  course  the  chief  agent 
that  maintains  the  blood-pressure  in  the  arte- 
ries, but  the  height  to  which  that  pressure  rises 
largely  depends  on  the  resistance  met  with  in 
the  arterioles  and  capillaries,  on  what  is  known 
as  peripheral  resistance,  but  also  on  the  re- 
sponse that  the  ventricle  is  able  to  make  to 
that  resistance.     Ower  says :  "  Given  a  normal 


ARTERIOSCLEROSIS  63 

ventricle,  the  arterial  tonus  largely  determines 
the  ventricular  response  and  the  level  of  the 
arterial  blood-pressure  :  and  there  is  the  key- 
note of  the  physiological  and  pathological 
variations  of  pressure." 

A  slight  increase  of  blood-pressure  and  re- 
sistance as  life  advances  seems  to  be  the  rule, 
and  to  meet  this  the  heart  slowly  and  steadily 
increases  in  size  and  weight,  this  increase  being 
chiefly  in  the  left  ventricle.  In  some  cases 
where  people  live  to  great  old  age,  this  rule 
perhaps  does  not  hold  good,  for  I  have  fre- 
quently observed  in  such  cases  no  increase  of 
blood-pressure  during  the  last  fifteen  or  twenty 
years  of  life,  and  as  far  as  one  can  judge  no 
increase  in  the  size  of  the  heart.  In  some  of 
these  cases  the  blood-pressure  is  continually 
below  the  normal ;  that  is  to  say,  130-135  mm. 

Increased  arterial  resistance  soon  causes 
increase  of  the  size  of  the  ventricle,  and 
lengthens  the  duration  of  the  systole  and 
lessens  that  of  the  diastole  (thus  reducing  the 
resting  time  of  the  heart),  and  if  this  resistance 
persists  hypertrophy  must  ensue. 

This  hypertrophy  is  of  course  a  conservative 
effort  which  may  hold  the  field  for  a  long  time, 
but  eventually  degeneration  must  follow,  and 


64     ESSAYS  ON   PRACTICAL   MEDICINE 

then  dilatation,  which,  unless  cerebral  haemor- 
rhage occurs,  is  the  end  of  all  these  cases. 

With  this  knowledge  before  us  it  must  be 
evident  that  the  perfection  of  physical  life 
depends  on  the  anatomical  perfection  and  on 
the  physiological  well-being  of  the  heart  and 
the  blood-vessels.  The  blood  is  not  the  Hfe 
and  the  heart  is  not  the  life — ^the  secret  of  this 
mystery  lies  far  deeper — ^but  both  are  life's 
indispensable  ministers. 

It  would  be  a  very  good  institution  for  all 
persons  of  middle  life  to  have  their  hearts 
and  arteries  tested  occasionally.  A  wise  phy- 
sician would  be  able  to  assure  them  that  all 
was  well,  or  he  would  be  able  to  correct  slight 
divergences  from  health,  and  to  advise  as  to 
the  mode  of  life  and  the  amount  of  work  that 
might  be  safely  done. 

If  we  find  a  man  to  be  in  the  pre-sclerotic 
stage,  what  can  we  do  ?  Firstly,  much  can  be 
done  by  comparative  rest,  by  early  hours  and 
long  nights  (the  arterial  pressure  after  a  long 
night's  rest  is  often  lo  mm.  below  the  average 
day  pressure),  by  cutting  down  extremes  of 
work  or  of  social  pleasures,  and  by  the  avoid- 
ance of  excitement  and  over-stimulation — in 
short,  by  resting  the  heart  and  by  lessening 


ARTERIOSCLEROSIS  65 

peripheral  resistance.  The  diet  should  be 
plain  and  simplified ;  red  meat  should  be  eaten 
in  great  moderation  and  not  more  than  once  a 
day.  There  is  no  need  for  an  absolute  purin- 
free  diet,  but  it  should  be  in  that  direction. 
Perhaps  the  chief  thing  is  to  avoid  the  flesh 
extracts,  such  as  strong  meat  soups  and  rich 
gravies  ;  for  this  reason  boiled  or  stewed  meats 
are  better  than  fried  or  roast ;  this  applies  to 
fish  and  chicken  also  ;  a  plain  grill  is  good,  but 
the  frying-pan  is  a  danger.  Vegetable  soups 
made  with  a  bone  stock  may  be  taken.  Cheese, 
eggs  and  milk  should  supply  the  greater  part 
of  the  nitrogen  food. 

In  cases,  even  early  ones,  when  there  is 
very  high  pressure,  and  especially  when  the 
cerebral  symptoms  are  prominent,  such  as  per- 
sistent occipital  headache,  vertigo  on  stooping, 
insomnia  and  tinnitus,  a  purin-free  diet  is 
advisable  for  a  time  at  any  rate.  It  may  be 
useful  as  a  reminder  to  give  the  following 
extract  from  Dr.  Cautley's  paper  on  "  Diet 
and  Dietetics  " : 

"A  purin-free  diet  can  be  devised  from  a 

combination  of  the  various  purin-free  foods. 

Nuts   are   the   most   nutritious  and    contain 

much    fat,  chestnuts  being  the  most  digest- 

5 


66     ESSAYS   ON   PRACTICAL   MEDICINE 


ible.  Macaroni,  dates,  raisins  and  cheese  are 
all  purin  free  and  are  in  order  of  nutritive 
value.  White  bread,  potato  and  milk  contain 
minute  traces,  but  so  minute  that  they  may 
be  considered  as  purin  free.  Cream,  butter, 
fats,  eggs,  apples,  grapes,  figs  and  honey  are 
also  purin  free. 

"  The  following  table  shows  what  foods  are 
rich  in  purin.  The  purin  contents  of  food  in 
grains  per  pound,  pint  or  teacup : 


Sweetbread 

.     70-43 

Beans 

.     4-16 

Liver 

19-26 

Lentils    . 

.     4'i6 

Beefsteak 

14-45 

Oatmeal 

.     3-45 

Sirloin    . 

.        9-13 

Asparagus 

.     1-50 

Chicken 

9'06 

Onion 

.     o-o6 

Loin  of  pork 

.      .  8-48 

Veal 

.       8-13 

Porter     . 

.     1-35 

Ham 

8.08 

Ale 

1*27 

Mutton 

•       6-75 

T,a.ger  beer 

i'09 

Salmon 

.       8.15 

Coffee      . 

.     170 

Halibut 

.       7-14 

Ceylon  tea 

,        I'2I 

Plaice     . 

.       5-56 

India  tea 

.    1-05 

Cod        .         .         , 

4.07 

China  tea 

.     0-75 

With  regard  to  alcohol,  one  must  say  that 
the  majority  of  such  patients  are  better  with- 
out it,  but  when  a  person  has  been  accus- 
tomed to  a  moderate  amount  taken  with  his 
food  it  does  not  always  do  to  suddenly  stop 
it.  The  digestion  may  suffer  and  the  general 
body  tone  be  depressed.     Alcohol  is  not  a 


ARTERIOSCLEROSIS  67 

pressure    elevator,    rather    the    opposite.     So 

many  of  these  patients  are  inclined  to  have 

gouty  tendencies  that  strong  wines  and  malt 

liquors  are  certainly  unsuitable.     A  little  light 

wine,  such  as  claret,  still  moselle  or  grave,  may 

do  no  harm  if  taken  with  the  meals  only,  and 

the  same  rule  applies  to  small  quantities  of  old 

matured  spirits.     Alcohol,  wisely  chosen,  and 

only  used  as  a  digestive  tonic,  may  help,  but 

when  used  as  a  frequent  stimulant  to  enable 

the  body  or  mind   to  do  more  work  or  to 

increase  endurance  for  pleasurable  excitement, 

it  certainly  does  harm.     Brunton  says  :    **  All 

the  alcohols  tend  to  dilate  vessels,  to  lessen 

blood-pressure    and    ultimately    to    diminish 

activity  of  the  nervous  tissues,  although  at 

first   they   may   seem   to   have   a   stimulant 

action."     In  another  place  he  says  :  "  Alcohol 

produces  dilatation  of  the  peripheral  vessels, 

and  tends  to  lower  the  blood-pressure,  while  at 

the  same  time  it  stimulates  the  heart."  Alcohol 

contains  so  little  nutritive  value   (with  the 

exception  of  the  sugars  and  extractives  of 

wines  and  beers)  that  in  itself  it  may  be  said 

to  give  nothing  to  the  body  ;   it  only  enables 

a  man  to  draw  on  his  reserves.     This  may  be 

useful  in  emergencies,  or  when  used  in  great 


68     ESSAYS  ON  PRACTICAL   MEDICINE 

moderation,  but  unless  so  used,  its  inevitable 
tendency  must  be  to  exhaust  the  reservoirs 
of  nervous  energy.  This  question  of  alcohol 
must  be  handled  by  physicians  on  a  thor- 
oughly scientific  basis.  We  shall  do  more  for 
the  cause  of  temperance  by  sober  judgment 
and  advice,  founded  on  scientific  facts,  than 
by  hot-headed,  unprovable  generalisations. 

Strong  coffee,  especially  black  coffee,  taken 
after  meals  is  certainly  a  stimulant,  but  is  a 
raiser  of  tension  ;  it  has  its  good  effects  as 
well  as  its  bad.  Many  folks  are  much  the 
better  for  a  good  cup  of  cafe  au  lait  in  the 
morning.  Tea  probably  does  not  raise  ten- 
sion to  any  extent,  but  taken  in  excess  may 
easily  produce  tachycardia  and  irregularity  of 
the  heart's  action,  especially  if  the  heart  is 
working  under  difficulties.  Good  China  tea 
seems  to  have  less  bad  effects  than  the  other 
growths,  but  it  is  not  quite  such  a  good 
stimulant. 

The  question  of  tobacco  is  very  frequently 
presented  to  us,  and  it  is  not  always  an  easy 
one  to  answer.  Nicotine,  no  doubt,  is  one  of 
the  most  powerful  raisers  of  tension  known, 
but  in  ordinary  forms  of  smoking  not  very 
much  gets  into  the  system.     Chewing  tobacco 


ARTERIOSCLEROSIS  69 

and  snuff-taking,   which  are  nearly  extinct, 
probably   introduce    more   nicotine   into    the 
body  than  any  form  of  smoking.     With  cigars 
the  combustion  is  so  complete  that  very  little 
of  the  poison  remains.     There  is  rather  more 
in  pipe  smoking.     In  cigarette  smoking  the 
combustion  is  nearly  as  complete  as  in  cigar 
smoking,  but  the  cigarette  smoker  probably 
smokes  much  more  tobacco  in  the  course  of 
the  day  than  a  cigar  smoker,  for  he  is  never 
satisfied.     The  habit  of  inhaling  the  smoke  of 
cigarettes  is,  however,  the  real  danger ;    the 
absorption    of    nicotine    from    the    bronchial 
mucous  membrane  is  very  rapid,  and  much 
more  is  absorbed  in  this  way  than  by  smoking 
through  the  mouth  alone.     The  other  chemical 
products    of    tobacco    combustion,    pyridine 
and  the  picoline  bases,  have  probably  their 
effects  on   the   vaso-motor  nerves  also,   but 
their  evil  influence  is  chiefly  shown  by  irri- 
tation of  the  pharyngeal  mucous  membrane. 
Oliver  in  his  experiments  has  found  that  in 
ordinary  people,  not  excessive  smokers,  tobacco 
raises  the  systolic  pressure  from  10  to  15  mm., 
but  does  not  raise  the  diastolic,  so  that  the 
variation  between  the  two  becomes  abnormal ; 
this   effect   soon    subsides   after    smoking   is 


70     ESSAYS   ON   PRACTICAL    MEDICINE 

finished — in  a  quarter  of  an  hour  or  so.  We 
all  know,  of  course,  from  experience  that 
excessive  smoking  often  produces  tachycardia 
and  other  rhythmical  disturbances,  and  even 
pretty  severe  cardiac  pain  ;  the  ultimate  effect 
of  really  excessive  smoking  is  great  feebleness 
of  heart  and  a  very  low  tension.  It  will 
readily  be  seen  that  a  drug  which  affects  the 
circulation  so  strongly  should,  in  cases  where 
the  arteries  are  diseased  or  in  an  abnorm.al 
state,  be  used  with  great  caution  and  in  great 
moderation.  Tobacco,  no  doubt,  has  a  quiet- 
ing and  soothing  effect  on  many  people  with 
irritable  nerves,  and  to  this  extent  may  be 
useful,  but  one  cannot  help  coming  to  the 
conclusion  that  the  average  man  who  shows  a 
tendency  towards  arterio-sclerosis  had  better 
give  it  up  entirely  ;  this  applies  especially 
to  men  who  lead  indoor  lives.  The  man 
threatened  with  this  disease  has  to  face  a  very 
serious  position,  and  should  take  no  chances. 
When  we  have  removed,  as  far  as  possible, 
all  deleterious  external  influences,  we  can  do 
much  to  help  our  patients  by  medicinal  treat- 
ment. The  old  routine  of  giving  iodide  of 
potassium  in  the  pre-sclerotic  stage  is,  I  think, 
a  mistake  ;    it  often  upsets  the  digestion  and 


ARTERIOSCLEROSIS  71 

depresses  without  doing  any  real  good.  The 
vaso-dilators  or  depressors  that  we  should  rely 
on  in  this  state  are  the  nitrites,  the  hippurates 
or  the  benzoates.  The  first  are  rapid  depres- 
sors, but  the  effect  is  rather  short-lived  ;  but 
the  two  latter  will  generally  do  all  we  want, 
and  their  action  is  more  sustained.  They 
cause  no  headache,  and  unless  given  in  un- 
necessarily large  doses  produce  no  feeling  of 
depression— indeed,  most  patients  feel  much 
the  better  for  them.  The  head  symptoms,  the 
vertigo,  the  noises  and  the  sense  of  brain 
fatigue  soon  disappear.  In  this  pre-sclerotic 
stage  there  is  very  often  some  dilatation  of 
the  heart,  as  one  would  naturally  expect,  and 
sometimes  an  irregularity  of  beat ;  this  con- 
dition is  soon  improved  by  full  doses  of 
strophanthus  or  sulphate  of  spartein  ;  in  most 
cases  these  drugs  are  to  be  preferred  to  digi- 
talis, and  though  not  so  powerful  in  their 
action  on  the  heart  muscle,  are  well  able  to 
cure  the  dilatation,  if  the  tension  be  reduced 
simultaneously.  In  laboratory  experiments, 
strophanthin  in  poisonous  doses  increases, 
arterial  pressure,  but  I  think  that  all  clinical 
experience  shows  that  in  ordinary  medicinal 
doses  of  the_  tincture  of  the  seeds,  this  drug, 


72     ESSAYS   ON   PRACTICAL   MEDICINE 

while  strengthening  the  heart-beat,  has  Httle 
or  no  action  in  contracting  the  arterioles.  It 
will  readily  be  seen  how  important  a  point 
this  is. 

Mackenzie,  as  the  result  of  experiments  on 
patients  at  the  Mount  Vernon  Hospital,  has 
come  to  the  conclusion  that  digitalis  does  not 
often  raise  arterial  pressure,  but  that  in  some 
cases  it  even  lowers  it.     These  observations 
were,  in  his  hands,  made  with  the  extreme 
care  that  we  should  expect  from  him,  but 
I  cannot  help  feeling  that  there  is  a  partial 
error  somewhere.     His  patients  were  at  rest 
and  otherwise  placed  in  favourable  conditions, 
but  I  think  strongly  that  clinical  observations 
of  patients  leading  ordinary  lives  would  give 
different  results.     It  is  a  question  that  ought 
to  be  settled  as  far  as  possible,  for  digitalis  is, 
without  doubt,  the  most  useful  and  powerful 
heart  tonic  of  vegetable  origin  that  we  possess, 
and  if  there  are  dangers  in  its  use  we  should 
have  clear  signals  to  warn  us.     Dr.   F.   W. 
Price  confirms  Mackenzie's  views  on  its  pro- 
ducing no  rise  of  tension.     On  the  other  side 
Lauder  Brunton  says  :    *'  It  is  now  generally 
recognised  that  digitalis  has  (i)  the  power  of 
slowing  the  heart ;    (2)  of  making  it  stronger  ; 


A  R  TERIO-SCLEROSIS  73 

(3)  of  contracting  the  vessels."  In  his  resume 
at  the  end  of  the  chapter,  he  says  :  "  DigitaHs 
acts  on  the  cardiac  muscle,  the  intrinsic  cardiac 
nerve,  and  the  vagus  centre  in  the  medulla. 
It  also  affects  the  arterioles,  causing  them  to 
contract ;  and  probably  it  has  upon  them  also 
a  twofold  action,  as  on  the  heart,  stimulating 
both  the  contractile  muscular  walls  and  the 
nerves  which  go  with  them." 

Sir  William  Whitla,  a  very  careful  clinical 
observer,  says  :  "Its  action  upon  the  arterioles 
must  always  be  remembered,  for  by  increasing 
peripheral  resistance  it  raises  the  renal  and 
general  blood-pressure,  and  to  this  is  attri- 
buted its  striking  value  when  dropsy  has 
occurred."  When  the  arterial  tension  is  al- 
ready high,  as  in  valvular  disease  or  Bright's 
disease,  it  may  be  necessary  to  administer  a 
vaso-dilator  in  combination  with  it.  Clifford 
Allbutt  in  his  fifth  volume  of  his  Dictionary  of 
Medicine,  p.  961,  says  :  '*  Tone  we  may  define 
as  that  property  in  heart,  artery  or  other 
hollow  viscus  which  preserves  the  mean 
diameter  of  the  part ;  contraction  as  that 
which  enables  the  organ,  nevertheless,  to  obey 
stimulus  and  to  perform  particular  acts.  The 
vermicular  movements  of  the  bowel  and  of  an 


74     ESSAYS   ON  PRACTICAL   MEDICINE 

arteriole  are  due  to  the  quality  of  contracti- 
bility ;  their  tone  preserves  their  mean  dia- 
meters in  spite  of  distension  or  contraction. 
Were  it  not  for  tone  a  hollow  organ,  often 
subject  to  extravagant  demands,  would  be 
strained,  and  perhaps  ruptured.  In  the  heart 
it  is  tone  which  does  much,  if  not  all,  to  pre- 
vent loss  of  form  under  the  great  variations 
of  internal  pressure/'  Farther  on  he  says, 
as  the  result  of  his  experiments,  "  that  digi- 
talis produces  a  distinct  increase  of  tone, 
which  may  be  pushed  to  a  degree  inconsistent 
with  normal  function/ '  Again  he  says  :  ' '  Tone, 
then,  is  the  quality  to  be  watched  and  sup- 
ported, and  in  digitalis  we  have  a  means 
of  intensifying  tone  and  of  moderating  dis- 
tensibility.  Now  tone,  like  any  other  quality 
in  excess,  may  be  injurious,  and  the  output 
of  the  constringed  ventricle  may  fall  short  of 
the  demands  of  the  system.  Again,  when  the 
muscle  falls  into  degeneration  digitalis  seems 
to  have  other  injurious  actions,  the  nature  of 
which  is  obscure."  May  we  not  extend  this 
argument  from  the  ventricular  muscle  to  the 
arterial  muscular  coats  ?  And  will  not  obser- 
vation of  arterial  pressure  be  the  guide  to  the 
use  of  this   powerful,  remedy  ?     If  we  giv^ 


ARTERIOSCLEROSIS  75 

enough  digitalis  to  render  perfect  the  tone  of 
the  ventricle  and  not  to  pass  beyond  that 
point,  we  shall  probably  be  doing  the  same  for 
the  musculature  of  the  arterioles,  and  thereby 
improve  the  general  condition  of  the  circula- 
tion and  also  the  nutrition  of  the  arterial  coats 
themselves.  But  if  we  press  beyond  this 
normal  tone  point,  it  is  easily  seen  that  we 
increase  peripheral  resistance,  and  so  embarrass 
and  add  to  the  work  of  the  heart.  In  arterio- 
sclerosis, I  think,  we  often  get  signs  of  arterial 
degeneration  before  those  of  cardiac  degenera- 
tion, and  in  such  circumstances  it  may  be  that 
digitalis  is  especially  harmful.  The  lesson, 
then,  to  learn  is  that  when  using  digitalis 
as  a  heart  tonic  in  arterio-sclerosis,  we  must 
carefully  and  frequently  watch  the  tension, 
and  we  must  stop  the  drug  for  a  time  if  there 
be  any  marked  increase,  and  especially  if  there 
be  a  marked  diminution  of  urine. 

The  following  is  an  attempt  to  formulate, 
for  practical  purposes,  our  present  knowledge 
of  the  action  of  digitalis  and  of  its  sphere  of 
usefulness.  By  its  action  on  the  vagus  and 
the  intrinsic  nerves  of  the  heart,  it  improves 
stimulus,  it  soothes  and  lessens  excitability, 
and  by  so  doing  improves  and  regulates  cou- 


76     ESSAYS   ON   PRACTICAL    MEDICINE 

ductivity  and  rhythm.  It  decidedly  increases 
contractility — so  much  so  that  a  poisonous 
dose  may  cause  the  heart  to  stop  in  a  state 
of  systole  ;  it  increases  also  tonicity  and  so 
prevents  the  tendency  to  dilatation  from  in- 
ternal pressure  ;  but  under  excessive  doses 
this  tonicity  may  be  so  augmented  that  the 
ventricle,  not  dilating  sufficiently,  is  unable  to 
receive  and  consequently  to  discharge  the 
normal  quantity  of  blood  into  the  arteries. 
Its  general  effect,  under  wise  dosage,  is  to 
improve  the  power  and  the  nutrition  of  the 
heart  muscle,  and  this  result  is  not  a  mere 
passing  thing.  Its  sphere  of  usefulness  is 
chiefly  in  cases  of  commencing  or  partial  failure 
of  heart  power  and  tone,  and  it  may  be  given, 
with  watchfulness,  in  any  such  case,  whatever 
the  valvular  defects  may  be,  though  it  will  be 
better  borne  in  some  valvular  diseases  than  in 
others.  In  disorders  of  cardiac  rhythm,  such  as 
auricular  fibrillation  and  flutter,  it  is  especially 
indicated  ;  in  most  cases  of  dropsy,  resulting 
from  circulatory  failure,  it  is  invaluable. 

It  should  not  be  used  in  conditions  of  acute 
myocarditis,  which  so  often  occur  in  the  in- 
fective fevers,  and  after  this  condition  has 
passed  away  it  should  not  be  given  if  the 


ARTERIOSCLEROSIS  77 

heart  muscle  is  producing  good  compensation 
by  itself — first  let  the  natural  powers  of  re- 
cuperation have  their  chance.  It  should  be 
given  with  great  caution  where  there  is  much 
peripheral  obstruction  in  the  arterioles,  as  in 
advanced  sclerosis  and  in  Bright's  disease 
where  there  is  high  tension,  but  even  in  such 
cases  it  may  be  most  useful  if  combined 
with  vaso-dilators.  In  cases  of  extreme  myo- 
cardiac  degeneration,  where  there  is  no  healthy 
muscle  to  respond,  it  will  probably  do  harm, 
and  cannot  do  good. 

We  have,  then,  in  our  hands  a  very  powerful 
and  useful  weapon,  but  we  must  see  that  we 
do  not  draw  it  in  a  wrong  cause. 

To  return  to  the  treatment  of  the  arteries 
in  the  pre-sclerotic  stage  ;  when  the  heart 
dilatation  is  cured  by  this  combined  treatment 
of  tonics  and  vaso-dilators,  it  should  not  be 
difficult  to  keep  the  tension  at  the  normal 
point,  but  thesp  cases  will,  for  some  time,  need 
careful  watching  and  guiding  ;  there  is  always 
a  tendency  for  both  the  patient  and  his 
arteries  to  relapse.  The  hippurates  should  be 
given  steadily  for  some  months,  but  in  dimin- 
ishing doses.  The  salts  in  use  are  the  sodium, 
the  lithium  and  the  ammonium  hippurate — 


78     ESSAYS   ON   PRACTICAL    MEDICINE 

of  which,  I  think,  the  lithium  is  rather  the 
strongest.     From  five  to  ten  grains  daily  are 
generally   sufficient,    but   the    dose   may   be 
pushed  further  if  the  patient  is  under  observa- 
tion.    I  have  not  so  much  experience  of  the 
benzoates,  but  here  we  should  have  to  use 
larger  doses — thirty  grains  a   day  or  more. 
The  benzoates  are  not  so  well  borne  by  the 
stomach  as  the  hippurates.     The  nitrite  group 
is   represented   by   sodium   nitrite,   mannitol 
nitrate,     erythrol    tetranitrate,     and    liquor 
trinitrin,  the  dose  of  the  three  former  being 
about  one  to  two  grains  three  times  a  day, 
and  of  the  liquor  trinitrin  one  or  two  minims 
three  times  a  day.     The  effect  of  the  mannitol 
and  erythrol  is  probably  more  sustained.     All 
these  may  cause  headache,  which  the  hippu- 
rates do  not.     When  these  simple  remedies 
fail  to  materially  reduce  tension  and  to  give 
relief  to  the  subjective  symptoms,  we  may  feel 
almost  sure  that  the  disease  has  gone  beyond 
the  pre-sclerotic  stage,  and  that  we  have  to 
deal   with   actually   thickened   arteries.     We 
may  have  to  deal  also  with  a  hypertrophied 
heart  and  with  commencing  cardio-sclerosis ; 
the    problem    thus    becomes    more    compli- 
cated. 


ARTERIOSCLEROSIS  79 

A  most  important  point  now  is  the  state  of 
the  kidneys ;  if  there  is  no  albuminuria  we 
may  do  much  to  alleviate  symptoms  and  to 
prevent  further  progress  of  the  disease.  After 
careful  ordering  of  the  patient's  life,  we  should 
steadily  try  to  reduce  the  tension  and  to 
strengthen  the  heart's  action,  as  in  the  early 
stage,  but  it  will  need  much  care.  Where 
there  is  confirmed  sclerosis,  the  point  of 
normal  tension,  as  concerns  each  individual, 
is  no  longer  constant.  One  must  try  to  find 
that  point  in  each  case,  by  watching  and  by 
the  patient's  own  sense  of  well-being.  In 
some  cases  you  can  get  tension  down  to 
140  mm.  and  they  feel  much  the  better  for  it ; 
others  would  get  irregular  heart  action  and 
be  miserable.  The  extreme  degrees  of  tension 
such  as  200  mm.  and  over  should  certainly, 
I  think,  be  attacked,  but  there  are  very  many 
cases  who  do  well  and  lead  fairly  comfortable 
lives  by  the  tension  point  being  reduced  to 
160  or  170  mm.  These  patients,  if  the  kidneys 
are  fairly  sound  and  if  they  lead  careful 
abstemious  lives,  may  live  to  real  old  age, 
but  they  should  be  often  under  supervision  ; 
till  they  are  well  on  to  eighty  they  will  often 
need  medicinal  help  ;    after  eighty  generally 


8o     ESSAYS  ON  PRACTICAL   MEDICINE 

the  tendency  to  progressive  sclerosis  ceases, 
the  arteries  become  softer,  and  the  general 
circulatory  stress  becomes  less.  The  same 
drugs  will  help  much  in  all  these  cases.  An 
uncertain  proportion  of  sclerotic  cases  will 
develop  atheroma  of  the  arteries  ;  the  serious- 
ness of  this  varies  much  with  the  site  of  the 
affection.  One  often  detects  marked  atheroma 
in  the  radial,  brachial  or  temporal  arteries 
without  any  special  symptoms  being  produced. 
The  danger  point  is  in  the  aorta  and  cerebral 
arteries  ;  cerebral  haemorrhage  is  of  course  the 
danger  here.  In  atheromatous  conditions  the 
tension  varies  much,  at  any  rate  as  measured 
by  our  present  instruments ;  it  is  some- 
times normal  or  below  normal.  When  it  is 
high  it  should  be  reduced  with  extreme  cau- 
tion. In  many  such  cases  nature  has  estab- 
lished a  working  equilibrium  or  compromise 
that  is  better  left  alone  ;  all  we  can  do  is  to 
help  the  heart  and  blood-vessels  to  carry  on 
with  the  smallest  amount  of  strain.  Attention 
to  the  action  of  the  liver  and  bowels  will  be 
very  important  and  regulation  of  bodily  work. 
In  the  cases  of  sclerosis  at  any  stage,  where 
there  are  clear  signs  of  kidney  disease,  the 
outlook  is,  of  course,  not  so  good,  but  still 


ARTERIOSCLEROSIS 


much  can  be  done  to  help.  The  reduction  of 
tension  in  the  general  arterial  system  will 
affect  the  kidney  vessels  also,  and  lessen  con- 
gestion ;  it  will  probably  help  also  towards 
better  elimination.  The  action  of  over-dosage 
of  digitalis  in  causing  contraction  of  the 
kidney  arteries,  and  so  in  producing  suppres- 
sion of  the  urinary  excretions,  shows  how 
important  the  question  of  vaso-dilation  be- 
comes to  a  diseased  kidney.  The  old  woman's 
remedy,  broom  tea,  represented  now  by 
sulphate  of  spartein,  was  undoubtedly  a 
good  diuretic,  but  better  in  cardiac  dropsy 
than  in  that  of  Bright's  disease  probably. 
This  effect  was  produced  apparently  by  the 
drug's  action  on  the  heart  muscle,  with- 
out its  producing  any  contraction  of  the 
muscular  coats  of  the  arteries.  It  would  be 
outside  the  scope  of  this  essay  to  deal  at 
greater  length  with  the  kidney  side  of  the 
question. 

In  some  sclerotic  cases,  especially  where 
there  is  a  tendency  to  obesity,  thyroid  feeding 
may  be  of  great  use,  and  will  in  the  future, 
perhaps  to  a  great  extent,  supersede  other 
medicinal  treatment.  Though  laboratory  ex- 
periments show  some  divergence  of  results,  I 
6 


82     ESSAYS   ON   PRACTICAL   MEDICINE 

think  we  must  regard  it  as  an  established  fact 
that  thyroid  extract  is  a  tension  depressor. 
The  original  experiments  by  OHver  and 
Schafer  seem  conclusive,  and  Biedl  in  his  work 
on  the  internal  secretory  organs  corroborates 
these  conclusions.  Brunton  says  :  "  Thyroid 
gland,  when  taken  by  the  mouth,  dilates  the 
peripheral  vessels,  makes  the  skin  warm  and 
moist,  and  quickens  the  pulse.  In  this  respect 
it  antagonises  the  suprarenal  secretion.  Be- 
sides this  effect  on  the  blood-pressure  it  has 
other  effects  on  metabolism  which  are  im- 
portant." Biedl  says  :  ''If  thyroid  extract  or 
iodothyrin  are  given  continuously  for  two  or 
three  weeks,  the  amount  of  COg  excretion  will 
be  increased  by  15  to  25  per  cent.  The 
nitrogenous  interchanges  are  invariably  dis- 
turbed by  th3n:oid  extract ;  the  increased 
decomposition  of  albumen  is  expressed  by  an 
increased  excretion  of  nitrogen.  By  increasing 
the  caloric  food  supply,  the  nitrogen  losses  may 
be  avoided.  In  obesity,  owing  to  the  large 
reserve  of  fat,  the  loss  of  albumen  is  not  as 
great  as  in  the  normal  subject.  Thjnroidism 
also  brings  about  a  considerable  increase  in  the 
amount  of  calcium  excreted  in  the  faeces,  the 
calcium  carrying  off  with  it  a  large  proportion 


ARTERIOSCLEROSIS  83 

of  phosphorus.  Scholz  had  before  shown  that 
thyroid  extract  produces  in  man  an  increased 
excretion  of  phosphorus."  It  is  very  evident 
that  we  have  in  thyroid  medication  something 
much  more  than  a  mere  tension  depressor. 
Its  other  properties,  influencing  the  excretions, 
explain  to  some  extent  its  sphere  of  usefuhiess 
and  its  drawbacks.  The  increased  excretion 
of  calcium  may  be  very  beneficial  in  sclerosis, 
especially  perhaps  when  there  is  atheroma  ; 
the  loss  of  phosphorus  accounts  in  some 
measure  for  the  debility  and  for  the  nervous 
symptoms  that  often  follow  its  use.  The  in- 
creased output  of  CO,  and  N  is  probably  all 
helpful,  but  all  these  by-effects  should  be  pro- 
duced slowly  and  cautiously.  I  have  thought 
that  thyroid  treatment  in  sclerosis  is  more 
satisfactory  in  cases  where  there  is  no  kidney 
complication  ;  this  is  not  unlikely,  as  in 
Bright's  disease  the  kidneys  would  only  im- 
perfectly carry  off  the  results  of  increased 
nitrogen  metabolism,  and  this  failure  of  ex- 
cretion would  leave  the  blood  overcharged 
with  these  products.  An  Eastern  proverb 
says,  "  Don't  stir  up  sleeping  dogs  if  you 
can't  kick  them  off  the  premises,"  the  moral 
of  which  is  not  difficult  to  see.     The  loss  of 


84     ESSAYS   ON  PRACTICAL   MEDICINE 

phosphorus  can  be  well  remedied  by  giving 
lecithin.  We  should  bear  in  mind  that  thyroid 
extract  and  parathyroid  extract  are  in  some 
measure  antagonistic ;  thyroid  contains,  in 
Schafer's  language;  an  autacoid  or  stimulator 
of  nervous  energy  and  of  some  other  excretory 
glands,  as  the  suprarenal ;  parathyroid  ex- 
tract contains  a  chalone  and  has  the  reverse 
effect.  I  cannot  help  thinking  that  some  of 
our  therapeutic  experiments  are  brought  to 
naught  by  preparations  carelessly  made  and 
containing  the  extracts  of  both  glands.  In 
thyroid  treatment  we  must  stop  short,  if 
we  can,  of  producing  its  disagreeable  effects, 
palpitation  of  the  heart  and  giddiness  ;  the 
sphygmo-manometer  is  generally  a  good  guide, 
but  if  these  symptoms  come  on,  they  are 
generally  relieved  most  effectually  by  supra- 
renal extract,  a  5-grain  tablet  once  or  twice 
daily  :  this  sounds  like  an  illogical  proceeding, 
where  you  are  trying  to  lower  pressure,  but  in 
practice  it  succeeds  well.  It  is  well  known 
that  thyroid  exhibition  in  health  increases  the 
amount  of  adrenine  in  the  blood  ;  this  is  prob- 
ably a  wise  compensation,  and  one  can  readily 
understand  how  in  disease  this  compensation 
may  fail  to  take  place.     Though  in  obesity 


ARTERIOSCLEROSIS  85 

thyroid  often  causes  loss  of  weight,  in  thin 
people  who  are  suffering  from  hypo-thyxoidism 
it  often  has  the  opposite  effect.  In  thyroid 
treatment,  especially  as  old  age  draws  near, 
and  quite  apart  from  myxoedema,  we  have 
before  us  a  most  interesting  field  of  study,  full 
of  possibilities  and  of  hope. 

The  addition  of  other  gland  extracts  to  thy- 
roid are  extremely  useful ;  they  counteract  the 
lowering  effects  and  enable  us  to  greatly  prolong 
its  use. 

In  arterial  sclerosis  I  nearly  always  use 
testicular,  ovarian  and  anterior  pituitary 
(pitglandin)  with  th37roid.  The  anterior  pitui- 
tary of  these  three  is  far  the  most  important  in 
my  opinion,  for  it  is  a  real  tonic  as  well  as  a 
tension  depressor.  This  I  shall  discuss  in  the 
next  chapter ;  but  in  passing  I  should  like  to  say 
that  the  ovarian  and  testicular  extracts  seem 
to  act  with  greater  effect  on  the  opposite  sex. 
In  Russia  caviare,  the  roe  of  the  female  fish, 
is  universally  regarded  as  an  aphrodisiac  for 
men.  In  women  about  the  climacteric,  when 
there  is  depression  with  some  high  tension, 
testicular  extract  in  the  form  of  Burroughs  & 
Wellcome's  didymin  often  gives  a  new  mental 
outlook. 


86     ESSAYS   ON   PRACTICAL   MEDICINE 
The  formula  I  use  is  as  follows  : 

Thyroid  dried  extract         .  .  .  grain  J 

Ovarian      „             ,,             •  .  •  ,,     J 

Testicular  ,,             ,,             .  .  .  ,,     ^ 

Anterior  pituitary  (pitglandin)  .  •  „     i 

in  tablets  i  ter  die  ant.  cib. 

With  my  present  knowledge  and  experience 
this  is  generally  the  most  satisfactory  and 
efficient  direct  depressor  of  tension  that  I  know. 
It  acts  better,  I  think,  in  the  later  stages  and  in 
old  age  than  the  hippurates,  but  may  be  com- 
bined with  them.  The  thyroid  proportion  can 
be  safely  increased,  if  the  pressure  do  not  fall, 
and  either  the  ovarian  or  testicular  extract  can 
be  left  out. 

Still,  I  have  seen  many  cases  in  which  hip- 
purate  alone  has  kept  high  pressures  at  a  safe 
level  through  many  years,  and  in  real  old  age 
cases  in  which  the  gland  extracts  have  not 
apparently  been  of  help.  I  still  feel  unable 
to  say  positively  which  line  of  treatment  will 
succeed  the  better  in  any  individual  case.  E.g. 
I  have  one  lady  (ninety-six),  whose  brain  gets 
clouded  and  who,  to  use  her  own  expression, 
sees  visions,  when  her  pressure  rises  above 
155°^.  In  this  case  hippurate  acts  like  a 
charm,  and  she  calls  it  her  vision  medicine. 


ARTERIOSCLEROSIS  87 

Whatever  its  mode  of  action  may  be,  we  must 
not  forget  that  it  is  just  as  much  a  native 
organic  medicine  as  the  gland  extracts. 

For  many  years  iodide  of  potassium  has  had 
a  great  reputation  in  the  treatment  of  arterio- 
sclerosis, and  it  apparently  does  do  good  in 
certain  cases  ;  but,  as  far  as  experiments  show, 
it  has  no  direct  effect  in  lowering  blood- 
pressure  ;  it  is  quite  hkely  that  it  acts,  as  all 
preparations  of  iodine  do,  by  stimulating  and 
increasing  the  output  of  the  thyroid  secretion. 
It  is  a  disagreeable  drug  to  take,  depressing, 
and  not  always  easily  digested  ;  and  thyroid 
itself  should,  in  my  opinion,  be  tried  first. 
The  new  coUosol  iodine  may  give  more  constant 
results.  Rendle  Short  says  :  "  An  increased 
th3n:oid  secretion  may  be  obtained  by  giving 
iodides.  Here  we  find  the  explanation,  so  long 
sought  in  vain,  of  the  effects  of  iodides  on 
gummata,  arterio-sclerosis  and  aneurism.  The 
beneficial  agent  is  really  the  increased  internal 
secretion  of  the  th3nroid  gland.  Two  im- 
portant results  of  observation  and  experiment 
confirm  this  theory. 

"  In  the  first  place,  in  cases  of  myxcedema, 
arterio-sclerosis  is  early  and  intense.  The 
same  is  true  in  animals  after  removal  of  the 


88     ESSAYS   ON   PRACTICAL   MEDICINE 

thyroid.  Eiselsberg  gives  a  number  of  very 
convincing  photographs  of  intense  atheroma 
of  the  aorta  in  his  cretin  lambs  from  which 
the  thyroid  had  been  removed.  In  the  second 
place,  thyroid  extract  has  a  wonderful  power 
over  young  connective  tissue,  as  is  seen  by 
the  way  in  which  it  absorbs  the  subcuta- 
neous thickening  of  myxcedema  and  cretinism. 
It  is  not  surprising,  therefore,  that  it  should 
be  able  to  deal  also  with  gummata  and 
atheroma." 

With  these  facts  before  us,  is  it  unreasonable 
to  think  that  the  subthyroidism  which  is  so 
common  as  old  age  approaches  is  one,  if  not 
the  chief,  cause  of  atheroma  ?  And  is  it  not 
reasonable  to  expect  that  in  such  cases  thyroid 
feeding  will  prevent  the  extension  of  the 
disease  and  will  very  possibly  cause  absorption 
of  the  morbid  deposits  already  present  ? 

In  the  general  management  of  sclerotic 
patients,  plenty  of  fresh  air  is  necessary,  and 
steady,  moderate  exercise ;  their  inclination 
is  to  lead  a  sedentary,  indoor  life,  but  this  is 
distinctly  bad  for  them.  Physical  exercise 
must  be  of  a  nature  that  puts  no  great  strain 
on  the  heart  and  lungs,  and  to  ensure  this 
hurry  must  be  avoided  :  not  hurry  alone,  but 


ARTERIOSCLEROSIS  89 

even  the  feeling  of  being  hurried  or  rushed, 
raises  the  arterial  pressure,  before  any  move- 
ment has  begun.  Horace's  advice,  '*  sequam 
memento  rebus  in  arduis  servare  mentem," 
applies  with  double  force  to  such  folk. 

The  best  exercise  is  probably  walking,  on 
the  flat  at  first,  and  subsequently,  as  improve- 
ment takes  place,  up  graduated  inclines. 
Cycling  or^  better  still,  tricycling  when  roads 
and  winds  are  not  unfavourable,  is  good,  and 
not  so  monotonous.  Horseback  exercise,  on  a 
horse  that  is  not  a  puller,  is  perhaps  the  best 
of  all.  Sculling,  again,  in  a  light  river  boat  is 
very  good  work,  and,  if  not  hurried,  puts  very 
little  strain  on  the  heart,  and  quietly  exercises 
most  of  the  body  muscles.  Well-regulated 
exercise  spreads  the  circulation  of  the  blood 
over  a  much  larger  area  ;  in  rest  the  blood,  to 
a  great  extent,  collects  in  our  internal  reser- 
voirs, but  exercise  sends  it  coursing  through 
aU  the  arterioles  and  capillaries  of  the  muscles 
of  our  limbs ;  thus  internal  congestion  and 
pressure  is  reheved.  Probably  with  a  seden- 
tary indoor  life  the  viscosity  of  the  blood  is 
increased — this  is  a  problem  that  needs  working 
out.  It  must  be  evident  that  an  increase  of 
viscosity  of  any  circulating  fluid  must  demand 


go     ESSAYS   ON   PRACTICAL   MEDICINE 

increased  force  from  the  central  driving  power. 
Oxygen,  without  doubt,  lessens  the  viscosity 
of  the  blood,  and  so  reduces  the  heart's 
work. 

Sir  Lauder  Brunton,  at  a  meeting  of  the 
Medical  Society  of  London  a  year  ago,  related 
a  very  instructive  case.  A  patient  with  ad- 
vanced kidney  disease  was  at  death's  door, 
and  it  was  thought  necessary  to  bleed  her,  but 
the  blood  could  not  be  got  to  flow  from  the 
vein  on  account  of  its  viscosity  ;  a  cylinder  of 
oxygen  was  in  the  room,  and  the  happy  thought 
came  to  him  to  use  it  as  an  inhalant  :  in  a  few 
minutes  the  blood  began  to  flow,  and  in  a  few 
minutes  more  there  was  a  full  stream.  This 
all  emphasises  the  need  and  advantage  of 
open  air. 

Here  I  must  draw  attention  to  the  great 
value  of  bleeding  in  cases  of  extreme  high 
tension,  and  especially  when  there  are  sjnmp- 
toms  of  threatening  apoplexy.  Bleeding  from 
the  arm  is  the  quickest  method,  but  if  there 
are  objections  to  this,  a  leech  or  two  over  each 
temple  and  two  or  more  at  the  back  of  the 
neck  will  answer  well ;  the  leech  bites  should, 
of  course,  be  kept  running  by  warm  fomenta- 
tions for  some  time.     But  here  also  we  must 


ARTERIOSCLEROSIS  91 

not  cast  back  to  the  old  error  that  blood- pressure 
is  the  result  of  increased  blood-mass,  for  the 
venous  system  has  plenty  of  stowage  room 
available  as  reservoirs,  and  we  must  have  seen 
many  cases  of  high  blood-pressure  in  thin 
people  with  no  sign  of  plethora  ;  still  judicious 
bleeding  may,  I  think,  relieve  local  plethora, 
especially  perhaps  in  the  head,  a  method  which 
Nature  follows  in  epistaxis.  The  good  that 
results  is  no  doubt  due  not  to  the  mere  empty- 
ing of  the  blood-vessels,  but  to  the  alteration  of 
the  quality  of  the  blood  ;  as  soon  as  the  vessels 
are  partially  emptied  of  the  blood,  they  fill 
up  again,  by  extracting  the  watery  constituents 
of  the  tissues,  and  thus  the  viscosity  of  the 
blood  is  reduced.  In  this  state  of  blood 
arsenic  seems  to  be  beneficial.  There  remains 
the  important  question  of  balneology  and 
electricity  in  the  treatment  of  this  disease. 
The  Nauheim  treatment,  as  carried  out  at 
Nauheim  especially,  acts  perhaps  as  much  in 
reducing  arterial  tension  and  peripheral  resist- 
ance as  in  causing  contraction  of  the  dilated 
heart ;  the  immediate  effect  of  the  bath  is  to 
produce  great  dilatation  of  the  surface  arteri- 
oles and  capillaries  of  the  skin,  in  fact  cutaneous 
hyperaemia  of  an  active  kind  ;    this  naturally 


92     ESSAYS   ON   PRACTICAL    MEDICINE 

lessens  the  amount  of  blood  in  the  important 
splanchnic  area,  and  so  relieves  the  work  of 
the  heart.  This  treatment  can  be  well  imitated 
at  home.  In  the  Practitioner  of  August  1912 
is  a  clear  and  instructive  article  by  Dr.  Thorne 
on  the  good  effect  of  the  Nauheim  treatment 
on  arterio-sclerosis  as  carried  out  in  England. 
Other  waters  have  a  somewhat  similar  action — 
for  instance,  Gastein  and  Llangammarch  Wells 
in  Wales  ;  it  is  probable  that  the  radio-active 
character  of  some  of  these  waters  adds  to 
their  usefulness. 

Electrical  treatment,  where  obtainable,  may 
be  a  great  help.  In  the  early  stages,  I  think, 
high  frequency  is  of  some  considerable  help  in 
reducing  blood-pressure,  and  its  action  is  more 
than  a  passing  one  ;  it  also  acts  as  a  general 
tonic  to  the  vaso-motor  nerves  and  increases 
metabolism  probably  ;  in  the  later  or  con- 
firmed stages  of  sclerosis  it  is  not  of  much  use, 
I  think,  but  here  the  Bergonie-faradic  method 
seems  to  have  a  marked  effect  and  a  lasting 
one.  It  is  perhaps  hardly  necessary  to  say 
that  these  treatments  must  be  carried  out  by 
physicians  who  have  made  a  special  study  of 
electricity  and  who  know  its  limitations  and 
its  risks. 


ARTERIOSCLEROSIS  93 

When  all  has  been  said  about  the  treatment 
of  this  morbid  condition  we  call  arterio-sclero- 
sis,  we  are  sure  to  be  faced  with  a  somewhat 
sceptical  criticism  ;  one  will  ask,  '*  Is  not  this 
thickening  of  the  arterial  coats  and  its  in- 
crease of  tension  Nature's  method  of  keeping 
up  a  failing  circulation  ?  "  One  must  honestly 
answer,  "  Yes,  to  a  certain  extent  "  :  the  same 
criticism  would  apply  equally  to  the  case  of 
hypertrophy  of  the  ventricle,  which  grows 
stronger  and  bigger  only  to  meet  an  increased 
demand.  The  sclerosis  is  a  fault  to  compen- 
sate in  a  measure  for  another  fault ;  but  if  one 
can  remove  or  partialty  cure  the  originating 
and  causative  fault  one  may  and  should  surely 
treat  and  cure,  if  possible,  the  resulting  fault  ; 
it  cannot  be  our  duty  to  stand  by  and  see  the 
vicious  circle  of  disease  go  on  to  its  end  un- 
broken. The  original  causes  of  the  disease, 
except  in  those  sad  cases  where  the  tendency 
is  strongly  inherited,  are  largely  removable, 
for  mostly  they  arise  from  physiological  law 
breaking  and  from  mental  overstrain.  Let 
us  then  throw  aside  this  weight  of  paralysing 
hyper  criticism,  a  sin  that  doth  so  easily  beset 
us,  and  march  boldly  but  cautiously  on  in  the 
path  of  restoration  and  of  healing. 


94     ESSAYS   ON   PRACTICAL    MEDICINE 

Sir  Clifford  AUbutt,  in  his  inimitable  way, 
settles,  I  think,  this  question  as  follows: 

*'  In  entering  upon  the  discussion  of  vaso- 
dilatation, as  contrasted  with  agents  which 
bring  about  this  change  indirectly  by  modifying 
the  causes  of  morbid  constriction,  we  have  to 
consider  how  far  mere  dilatation — ^brought 
about,  that  is  to  say,  immediately  and  singly — 
serves  any  good  purpose. 

"  We  are  told  that  to  act  thus  directly  upon 
the  vessels  is  but  to  treat  a  symptom,  and 
is  therefore  absurd.  But  whatsoever  be  our 
judgment  on  this  or  any  such  particular  effect, 
the  common  denunciation  of  treating  symp- 
toms, which  sounds  very  philosophical,  is  surely 
but  a  parrot  phrase.  Why  should  we  not  treat 
a  symptom  ?  If  in  granular  kidney  by  mere 
pressure  reduction  the  grievous  headache  be 
abated,  or  in  angina  pectoris  the  pain  be  thus 
charmed  away,  we  have  so  far  at  any  rate  a 
substantial  gain. 

"  In  renal  diseases  it  is  generally  agreed  that 
on  the  whole,  with  due  caution,  to  lower  pressure 
is  helpful.  Moreover,  if  by  mitigation  of  his 
suffering,  the  patient  gets  a  chance  of  picking 
up  in  many  other  ways,  are  we  not  more  than 
justified  in  our  interference,  narrow  as  it  may 


A  RTERIO-SCLEROSIS  95 

seem  ?  We  never  know  what  interference  may 
cut  a  link  in  a  vicious  circle.  If  we  cannot 
stop  the  crack  in  the  water-pipe,  we  need  not 
throw  away  the  mop. 

*'  The  warning  should  run  not  against  the 
treatment  of  a  '  mere  symptom,'  but  lest, 
while  giving  our  attention  to  the  symptom 
and  snatching  at  an  immediate  advantage,  we 
lose  our  grip  of  the  case  as  a  whole." 

After  all  our  theories  and  speculations,  the 
high  court  that  has  to  pronounce  judgment  is 
formed  by  our  patients  themselves.  Ask  any 
man  or  woman  who  has  suffered  from  the 
miseries  and  discomforts  of  arterio-sclerosis, 
when  accompanied  by  high  blood-pressure, 
how  they  feel,  after  that  pressure  has  been 
carefully  and  judiciously  reduced,  and  you  will 
get  no  uncertain  answer.  They  can  work  and 
think  far  better  ;  their  breathing  is  much 
easier,  and  they  lose  the  cardiac  and  the 
cerebral  discomforts  that  made  their  lives  so 
miserable.  Their  sleep  becomes  again  quiet 
and  refreshing  ;  and  beyond  the  improvement 
in  these  subjective  symptoms,  there  is  a  con- 
dition of  far  better  general  health  and,  what 
is  perhaps  more  important,  of  greater  safety. 
It  must  be  evident  that  any  one  attempting  to 


96     ESSAYS   ON   PRACTICAL   MEDICINE 

lead  a  strenuous,  active  life,  either  in  mental 
or  bodily  work,  with  a  tension  much  above 
the  normal,  is  in  daily  danger  of  a  bad 
break-down,  of  one  that  will  practically  end 
his  working  days.  It  should  be,  therefore,  our 
manifest  duty  to  bring  all  such  to  the  know- 
ledge of  their  danger,  to  persuade  them  to 
lead  a  new  life,  and  to  grasp  the  means  of 
safety  that  we  can  offer  them. 

During  the  last  few  years,  it  has  been  the 
fortunate  lot  of  many  of  us  to  be  able,  with  our 
sclerotic  patients,  to  steer  them  safely  through 
the  dangerous  storms  and  shoals  of  later  middle 
age  into  the  quiet  and  restful  harbour  of  real 
old  age,  free  from  paralysis  and  with  mind 
unclouded. 


Ill 

THERAPEUTIC    SPECULATIONS   AND 
DOUBTS 

The  truest  courage  lies, 

Not  in  unseeing  eyes, 
Owning  no  danger,  blindly  rushing  on  ; 

But  in  the  eye  that  sees 

To  grasp  the  golden  keys 
Of  power  and  circumstance,  and  make  them  one. 

When  we,  in  all  honesty  and  out  of  our 
patients'  hearing,  take  stock  of  our  therapeutic 
experiences,  we  must,  I  think,  allow  that  our 
expectations  have  oftentimes  been  unfulfilled, 
or  that  the  results,  at  any  rate,  have  not  been 
commensurate  with  our  hopes.  That  this 
should  be  so  is  no  cause  for  wonder  and  cer- 
tainly no  cause  for  despair.  Till  quite  recently 
we  were  most  of  us  brought  up  in  a  school  of 
almost  pure  empiricism,  of  traditions,  and  often 
of  illogical  conclusions.  It  is  only  in  the  last 
twenty  or  thirty  years  that  either  the  plant 
remedies  or  the  chemical  ones  have  been 
studied  at  all  accurately  from  the  physiological 
7  97 


98     ESSAYS   ON   PRACTICAL   MEDICINE 

point  of  view,  and  the  results  tested  by  scien- 
tific methods  and  instruments.  Many  of  us 
can  remember  the  wave  of  pure  scepticism 
that  passed  over  the  medical  world  in  the  times 
of  Gull,  who  had  the  courage  to  treat  seventy 
cases  of  acute  rheumatism  with  the  old  alkahne 
potash  treatment,  another  seventy  cases  with 
peppermint  water,  and  to  pubUsh  his  results. 
This  scepticism  and  honest  criticism  undoubt- 
edly did  good — it  cleared  our  minds  of  a 
certain  amount  of  cant  and  of  ignorant  pre- 
judice— -but  in  itself  it  led  nowhere. 

If  in  therapeutics  we  lose  faith  and  hope, 
we  become  in  a  measure  paralysed,  and,  what 
is  perhaps  worse,  we  develop  an  underlying 
feeling  that  we  are  saiHng  under  false  colours 
and  are  not  giving  a  quid  pro  quo,  or  as  Good- 
hart  puts  it,  a  quo  pro  quid.  To-day  surely 
there  is  no  room  for  faithlessness  nor  for  hope- 
lessness ;  our  knowledge  is  infinitely  wider  and 
surer  ;  it  still  is  very  necessary  to  keep  the 
judicious  and  critical  mind,  but  our  power 
over  disease  is  daily  increasing.  The  effects 
of  the  plant  remedies  are  still  often  a  matter  of 
doubt,  though  the  standardisation  of  tinctures 
and  the  extraction  of  alkaloids  have  put  things 
on  much  surer  ground  ;  these  remedies,  though 


SPECULATIONS  AND   DOUBTS  99 

very  often  useful — some  of  them,  indeed,  being 
seemingly  indispensable — ^will  eventually,  I 
think,  lose  much  of  their  prominent  position, 
for  the  reason  that  they  are  foreign  to  the 
animal  system.  The  inorganic  remedies  come 
under  rather  a  different  heading  ;  many  of 
them,  like  iron,  arsenic,  iodine,  potash  and 
soda,  are  already  constituents  of  the  flesh  and 
blood,  and  in  a  measure  they  can  be  regarded 
as  body  foods  ;  but  the  great  future,  I  venture 
to  think,  belongs  to  the  organic  animal  reme- 
dies, to  the  ductless  gland  extracts,  and  to 
organic  chemistry. 

Still  lest  we  be  led  astray,  we  must  walk 
warily  and  diHgently  sift  the  many  observa- 
tions and  theories  that  are  brought  before 
us  :  the  old  difficult  fences  of  fost  hoc  and 
propter  hoc  may  easily  give  us  a  nasty  fall. 
The  unreflecting  mind  will  look  on  a  truth 
that  is  only  half  a  truth  as  much  the  same 
thing  as  a  lie  that  is  only  half  a  lie  ;  the 
immediate  present  result  may  be  the  same, 
but  the  difference  lies  in  the  intent.  If  the  in- 
vestigator be  honest  and  has  an  open  mind,  the 
half-tiuth  will  probably  become  a  whole  truth, 
though  perhaps  not  in  his  time  :  it  may  be  for 
others  to  enter  into  his  labours,  to  complete 


lOo     ESSAYS   ON   PRACTICAL    MEDICINE  }^ 

them  and  to  reap  the  reward  (Tulii  alter 
honores  applies  to  us  as  to  others) ;  but  the 
true  physician  seeks  not  his  own  glory  or 
honour.  A  man,  on  the  contrary,  who  starts 
with  a  half-lie,  whether  intentionally,  selfishly 
or  with  a  scarcely  recognised,  half- unconscious 
bias,  will  most  likely  complete  his  lie.  His 
labour  will  be  in  vain  and  the  truth  still  farther 
from  the  light. 

Very  few  of  us  have  the  true  Darwinian 
intellect,  the  calmly  calculating  mind  that  is 
never  in  a  hurry  and  that  accurately  weighs 
both  failure  and  success.  How  few  of  us  have 
the  moral  courage  to  retrace  our  steps  and  to 
own  that  we  have  been  marching  down  a  blind 
alley !  So  in  much  patience  we  must  possess 
our  souls. 

On  the  other  hand,  we  must  not  forget  that 
half-truths  have  an  almost  fatal  fascination 
for  small  minds,  and  sometimes,  alas !  for  big 
ones.  Professor  Macphail  says :  '*  A  lie  which 
is  only  half  a  lie  is  far  less  deadly  than  a  partial 
truth  which  is  believed  to  be  the  whole  truth." 
Partial  truths,  cherished  and  worshipped  by 
narrow  minds  as  whole  truths,  have  been 
the  teterrimae  causce  of  wars,  burnings  and 
persecutions  in  religious  history  and  in   the 


SPECULATIONS    AND   DOUBTS         loi 

march  of  science  almost  insurmountable  bar- 
ricades. The  truth,  the  whole  truth  and 
nothing  but  the  truth  in  many  things  on  this 
side  of  the  grave  may  be  an  unattainable  ideal, 
but  still  should  be  our  standard — our  grail. 
In  the  search  for  the  inner  secrets  of  life,  of 
which  endocrinology  is  a  most  important,  even 
fundamental  part,  can  we  hope  in  our  short  time 
to  find  the  whole  truth  ?  We  may  establish 
the  truth  of  separate  facts  as  we  go  along,  and 
we  may  build  reasonable  theories  on  them,  but 
the  whole,  the  ultimate  truth  must  still  be  a 
far-away  goal.  Meanwhile,  we  are  surely  justi- 
fied in  using  the  knowledge  we  have  gained  for 
our  bodies'  weal. 

So  that  we  may  get  a  clear  understanding 
of  the  nomenclature  of  this  subject,  I  propose 
to  adopt  the  terms  and  definitions  that  Sir 
Edward  Schafer  has  used  in  his  lectures. 

1.  Material  which  passes  into  the  blood  or 
lymph  from  any  tissue  or  cell  of  the  body  is 
termed  its  internal  secretion. 

2.  Organs  which,  so  far  as  is  known,  possess 
no  other  function  than  this,  are  called  inter- 
nally secreting  or  endocrine  organs  {evBov, 
within,  and  Kplvco,  to  separate). 

3.  This  term,  as  at  present  understood,  com- 


I02     ESSAYS   ON   PRACTICAL   MEDICINE 

prises  the  thyroid,  the  parathyroid,  the  supra- 
renal, the  pituitary  and  the  pineal  glands. 
(Other  glands,  like  the  pancreas,  the  ovary 
and  the  testis,  have  properties  to  some  extent 
similar  to  these  glands,  but  they  do  not  come 
so  definitely  under  the  head  of  internally 
secreting  organs,  as  they  have  in  a  sense  both 
internal  and  external  secretions.) 

Schafer's  definition,  then,  is  "an  organ 
which  is  known  to  form  some  specific  chemical 
substance  within  its  cells  and  which  passes 
this  directly  or  indirectly  into  the  blood 
stream.  The  substance  thus  formed  is  the 
active  material  of  its  secretion,  just  as  ptyalin 
is  the  active  agent  of  the  salivary  secretion  ;  but 
while  the  salivary  secretion  is  conveyed  by  a 
duct  to  the  exterior,  in  the  case  of  the  ductless 
glands  the  secretion  remains  within  the  body 
and  circulates  with  the  blood." 

The  active  agents  of  the  external  secretory 
organs  differ  from  those  of  the  internal  secre- 
tory organs,  in  that  they  belong  to  the  class 
called  enzymes,  and  that  they  are  of  the  nature 
of  a  ferment  and  are  destroyed  by  heat.  The 
active  agents  of  the  internal  secretory  organs 
are  not  so  complex,  and  are  not  destroyed 
by  boiling  ;  they  are  dialysable,  and  some  of 


SPECULATIONS   AND   DOUBTS         103 

them  can  be  isolated  in   a   crystalline  form  ; 
the  active  principle  of  the  adrenals  has  even 
been  made  synthetically.     They  act  quickly 
on  the  cells  which  they  influence,  and  when 
injected  into  the  blood  stream  have  an  im- 
mediate effect,  whereas  an  enzyme  acts  more 
gradually.     The  action  of  these  principles  is 
not    unlike    those    produced    by    the    active 
principles   of   drugs,    especially   by   those   of 
vegetable   origin.     They  also  operate  by  im- 
mediate chemical  action,  being  conveyed  to 
their  special  parts  by  the  circulating  blood. 
Like  drugs,  some  of  the  principles  contained 
in  these  extracts  act  by  exciting  or  stimulat- 
ing cell  functions,  others  by  depressing  such 
functions  ;  the  former  are  called  "  hormones  " 
{op/jLacD,  to  stir  up),  and  the  latter  "  chalones  " 
(xaXdco,    to    make    slack).      The    expression 
"hormone"    has    now    got    such    a    widely 
extended  meaning  that  Schafer  has  coined  a 
new  expressive  word,  ''autacoid"  (avT09,  self, 
a/co9,  a  remedy),  which  he  defines  thus  :   "An 
autacoid  is  a  specific  organic  substance  formed 
by  the  cells  of  one  organ  and  passed  from  them 
into  the  circulating  fluid  to  produce  effects 
upon  other  organs  similar  to  those  produced  by 
drugs.    Such  effects  are  either  in  the  direction 


I04     ESSAYS   ON   PRACTICAL   MEDICINE 


of  excitation,  in  which  case  the  endocrine  sub- 
stances producing  them  may  be  termed  excita- 
tory autacoids  and  so  would  come  under  the 
expression  *  hormones/  or  in  the  direction  of 
restraint  or  inhibition,  in  which  case  they  may 
be  termed  restraining  or  inhibiting  autacoids 
and  be  classed  as  *  chalones/  The  action 
of  an  autacoid  may  be  termed  hormonic  or 
chalonic  according  to  the  kind  of  effect  it 
produces. 

"  Some  autacoids  appear  to  produce  opposite 
results  in  different  parts  of  the  body  :  thus 
adrenine  causes  contraction  of  the  plain  muscles 
of  the  blood-vessels  and  inhibition  of  that  of  the 
intestines.  In  both  cases  the  action  may  be 
regarded  as  that  of  a  hormone,  for  both  effects 
are  produced  by  stimulation  of  the  end  sub- 
stance of  the  sympathetic  nerves.  The  possi- 
bility of  the  same  autacoid  acting  under  some 
circumstances  as  a  hormone  or  excitant  and 
under  others  as  a  chalone  or  depressant  must 
be  borne  in  mind.  This  illustrates  the  drug-Hke 
nature  of  these  principles,  for  such  inversion  of 
action  under  different  circumstances  is  known 
to  occur  with  some  alkaloids." 

For  a  more  scientific  and  complete  description 
of  this  most  interesting  subject  I  would  refer 


SPECULATIONS   AND   DOUBTS         105 

my  readers  to  "  An  Introduction  to  the  Study 
of  the  Endocrine  Glands  and  Internal  Secre- 
tions," by  Sir  Edward  Schafer,  published  by 
Stanford  University,  California,  19 14,  75  c, 
and  to  "  The  Internal  Secretions,"  by  Gley 
and  Fishberg  (Heinemann). 

What  a  field  for  study,  for  observation  and 
for  successful  practice  these  discoveries  open 
up  for  us,  one  must  at  once  perceive.  We 
begin  to  get  a  glimpse  of  the  innermost  secrets 
of  life — -of  those  marvellous  agencies  which 
maintain  the  physiological  equilibrium  of  our 
bodies,  and  which  under  ever-varying  circum- 
stances enable  us  to  fight  this  good  fight  of 
vitality  versus  decay.  The  I  knowledge  we 
have  already  obtained  has  produced  most 
important  results,  but  we  are  not  yet  with- 
in sight  of  the  horizon  of  the  therapeutic 
possibilities. 

These  ductless  glands,  by  their  secretions, 
control  and  activate  not  only  each  other  but 
the  great  sympathetic  nervous  system  and  all 
the  vital  processes  of  the  body.  The  secre- 
tions of  most  of  these  glands,  from  some 
points  of  view,  appear  to  be  antagonistic  to 
one  another,  but  from  other  points  of  view 
helpful  and  compensatory.     In  their  totality 


io6     ESSAYS   ON   PRACTICAL    MEDICINE 

they  are  the  essence  of  Hfe  itself.  Our  aim 
and  hope  must  be,  by  patient  study  and 
by  experiment,  to  bring  these  powerful  and 
apparently  divergent  remedies  into  such  use 
and  combination  that  they  will  make  harmony 
again  out  of  the  discord  we  call  disease. 

Dr.  Gley  has  introduced  another  word,  which 
perhaps  fills  a  gap,  harmozone  (from  the  Greek 
dpfjbdco,  I  rule  or  direct).  Physiological  experi- 
ments on  all  these  secretions  are  as  yet, 
in  many  cases,  inconclusive.  One  observer  is 
frequently  disproving  his  own  theories  or  those 
of  another,  or  else  methods  of  investigation 
are  proved  to  produce  compHcations  which  do 
not  occur  in  life  or  health.  Still,  there  is  much 
solid  groundwork — enough,  I  think,  for  practical 
physicians  to  proceed  actively  and  without 
fear  on  empiric  lines  ;  in  fact,  empiric  medicine 
will  oftentimes  prove  or  disprove  physiological 
theories,  and  will  guide  and  direct  the  thera- 
peutical applications  of  the  work  of  the  labora- 
tory. It  must  be  remembered  also  that  this 
clinical  experiment  can  be  carried  on  quite 
safely,  for  none  of  these  gland  extracts  are 
poisonous,  and  any  disturbances  of  function 
they  may  cause  soon  passes  away  or  can  be 
corrected  by  other  means, 


SPECULATIONS   AND   DOUBTS         107 

It  would  be  dif&cult  to  say  which  of  these 
glands  is  the  most  important,  but  the  thyroid, 
I  think,  must  come  first,  as  its  errors  appar- 
ently are  concerned  more  than  those  of  others 
with  the  ordinary  morbid  conditions  of  life. 
Without  going  into  the  anatomy,  the  histology, 
or  the  development  of  the  thyroid  apparatus, 
we  must  bear  in  mind  that  it  consists  in 
man  of  two  lobes  united  by  an  isthmus,  and 
of  four  parathyroids.  It  is  found  in  all  the 
vertebrates.  It  is  a  very  vascular  organ  and 
contains  many  lymphatics.  The  nerve  supply 
is  from  the  sympathetic  and  from  the  vagus, 
and  is  distributed  both  to  the  blood-vessels 
and  to  the  secreting  epithelium.  Its  vesicles 
contain  the  "  colloid,"  which  almost  for  certain 
contains  the  active  principle  of  the  gland  ; 
this  colloid  is  insoluble  in  ether,  alcohol  or 
water,  and  contains  iodine.  The  parathyroids 
are,  in  man,  closely  attached  to  the  thyroid, 
but  are  physiologically  distinct ;  vesicles  con- 
taining colloid  material  similar  to  that  of  the 
thyroid  are  often  found  in  them,  but  the 
similarity  of  the  chemical  nature  of  the  two 
colloids  is  not  proved.  If  the  thyroid  be 
completely  removed  and  one  or  more  para- 
thyroids be  left,  the  colloid-containing  vesicles 


io8     ESSAYS   ON   PRACTICAL   MEDICINE 

of  the  remaining  ones  increase  in  number  and 
size. 

The  normal  functions  of  the  thyroid  appara- 
tus can  be  best  arrived  at  in  the  first  place  by 
noting  the  effects  of  removal. 

If  the  parathyroids  be  completely  removed, 
most  animals  die  within  a  few  days  or  weeks  ; 
the  carnivora  are  the  more  rapidly  affected. 
The  symptoms  belong  chiefly  to  the  nervous 
system,  and  show  generally  exaggeration  of 
reflexes,  passing  on  into  clonic  muscular  con- 
tractions and  then  into  convulsions ;  the 
symptoms  closely  resemble  those  of  the  disease 
called  "  tetany."  This  disease  has  frequently 
occurred  in  man,  after  a  complete  removal  of 
the  whole  thyroid  and  parathyroid  apparatus, 
and  can  only  be  cured  by  a  successful  graft 
of  a  human  parathyroid.  In  operations  for 
removal  of  thyroid  tumours  it  is  necessary,  in 
order  to  prevent  these  dangerous  symptoms, 
to  leave  two  of  the  four  parathyroids.  The 
most  satisfactory  explanation  of  "  tetany " 
coming  after  parathyroid  removal  is  the  as- 
sumption that  they  give  to  the  blood  an 
autacoid  which  has  an  inhibiting  or  chalonic 
effect  on  over-excitation  of  nerve  cells.  The 
removal  of  parathyroids  in  growing  animals 


SPECULATIONS   AND   DOUBTS         109 

probably  causes  delay  in  the  growth  and 
development  of  bones  and  teeth.  The  effects 
of  removal  of  parathyroids  have  been  relieved 
by  the  injection  of  extract  of  parath5n:oid  ; 
pituitary  extract  is  reported  to  have  a  like 
effect.  Schafer  concludes  by  saying  that  no 
other  substance  appears  to  exhibit  the  specific 
action  on  the  nervous  system  of  this  para- 
thyroid autacoid. 

Ott  says  that  intravenous  injections  of  para- 
thyroid extract  have  quite  a  different  effect 
from  those  of  thyroid.  The  blood-pressure  is 
first  raised,  then  depressed  ;  there  is  an  in- 
creased respiratory  rate  ;  they  are  diuretic, 
acting  directly  on  the  renal  epithelium  ;  and  in 
large  doses  they  lower  the  body  temperature. 
Applied  locally  they  increase  contraction  of 
intestine  and  uterus  and  dilate  the  pupil. 

If  the  th3n:oid  be  removed  or  become  atro- 
phied (two  or  more  parathyroids  remaining), 
the  following  are  the  chief  symptoms,  these 
being  more  marked  in  the  young  than  in 
the  mature  :  arrest  of  growth,  especially  of  the 
skeleton,  and  delay  in  the  development  of  the 
generative  organs  ;  the  skin  is  swollen  and 
dry,  the  hair  thin,  the  face  pale  and  puffy, 
the  abdomen  swollen,  the  nose  depressed,  the 


no     ESSAYS   ON   PRACTICAL   MEDICINE 

hands  and  feet  podgy.  The  fontanelles  remain 
open,  the  muscles  are  weak,  and  the  higher 
functions  of  the  nervous  system  remain  un- 
developed, this  being  due  to  arrested  develop- 
ment of  the  cortex  cerebri.  In  short,  we  have 
the  condition  called  ''  cretinism."  This  con- 
dition may  be  sporadic  or  endemic,  the  former 
being  caused  by  early  atrophy  or  by  absence 
of  the  th57roid,  the  latter  by  goitrous  degenera- 
tion. McGarrison  says  that  in  India  there 
are  two  types,  the  myxoedematous  and  the 
nervous,  the  latter  presumably  being  associated 
with  parathyroid  deficiency.  The  first  type 
is  the  more  common  in  Europe.  These  symp- 
toms rarely  are  seen  till  some  little  time  after 
birth,  the  theory  being  that  the  th5^oid  in- 
sufficiency is  compensated  for  a  time  by  the 
autacoids  conveyed  from  the  mother,  before 
birth  by  the  placenta  and  afterwards  by  the 
milk.  If  thyroid  atrophy  comes  on  in  adult 
age,  the  condition  called  myxoedema  comes 
on.  This  also  frequently  supervenes  on  com- 
plete surgical  removal  of  the  gland.  Kocher 
says  :  ''  If  about  a  quarter  of  the  gland  is  left, 
the  symptoms  of  thyroid  insufficiency  do  not 
appear."  This  is  Schafer's  description  :  "It 
is  characterised  by  the  thickening  and  swelling 


SPECULATIONS   AND   DOUBTS         iii 

of  the  skin,  which  pits  on  pressure,  the  pitting 
disappearing  on  relaxing  the  pressure  ;  by  the 
skin  becoming  dry  and  the  hairs  faUing  out ; 
by  a  low  body  temperature,  by  mental  dull- 
ness, and  by  general  impairment  of  sensi- 
bility." Metabolism  is  lessened,  so  that  body 
weight  may  increase  in  spite  of  a  smaller  in- 
take of  food  ;  there  is  often  a  considerable 
deposition  of  fat,  especially  under  the  skin, 
and  there  is  a  diminished  amount  of  oxygen 
consumed  and  of  nitrogen  excreted.  There  is 
a  diminished  excretion  of  calcium  salts — ^after 
parath5n:oid  removal  only,  an  increase  of  this 
excretion  has  been  observed — ^and  there  is  an 
increased  tolerance  for  sugar  ;  in  th5n:oidecto- 
mised  animals  a  full  injection  of  adrenalin, 
which  in  ordinary  circumstances  would  pro- 
duce glycosuria,  fails  to  do  so  ;  in  this  respect 
also  the  thyroids  and  parathyroids  seem  to 
have  opposite  action.  The  skin  of  the  face 
is  often  affected  more  than  in  other  parts, 
especially  under  the  eyes,  and  gives  the  peculiar 
expressionless,  masklike  appearance  which  we 
associate  with  myxoedema.  The  general  con- 
clusions arrived  at  by  Biedl,  Eppinger  and 
others  seem  to  be  these  :  "  that  the  thyroid 
and  the  chroma ffine  system,  together  with  the 


112     ESSAYS   ON  PRACTICAL   MEDICINE 

infundibular  portion  of  the  hypophysis,  con- 
stitute a  group  of  vascular  glands  which 
augment  and  accelerate  the  processes  of  meta- 
bolism. The  balance  is  maintained  by  the 
antagonistic  activity  of  those  other  vascular 
glands  like  the  pancreas  and  the  parathyroids 
which  exercise  a  restraining  influence  upon 
metaboHsm.  These  two  groups  of  internal 
secretory  glands  possess  physiological  inter- 
relationships with  one  another  ;  the  extirpa- 
tion of  a  vascular  gland  is  followed  by  differing 
sets  of  phenomena.  Firstly,  there  are  the 
direct  results,  due  to  suppression  of  the  specific 
secretion ;  secondly,  there  are  the  indirect 
results,  due  to  derangement  of  other  glands, 
the  functions  of  which,  under  normal  condi- 
tions, were  either  stimulated  or  inhibited  by 
the  secretion  of  the  suppressed  gland.  The 
thyroid  is  believed  to  promote  the  activity  of 
the  chromafiine  system  and  to  inhibit  that  of 
the  pancreas.  The  direct  results  of  removal 
of  the  thyroid  consist  in  reduction  of  the 
metaboHsm  of  albumin,  fat  and  salts  ;  the  in- 
direct results  are  on  the  one  hand  the  absence 
of  stimulation  of  the  chromafhne  system,  and 
on  the  other  a  hyper-activity  of  the  pancreas 
due  to  the  removal  of  the  inhibitory  agent.     It 


SPECULATIONS  AND   DOUBTS        113 

is  believed  that  the  nervous  system  is  the 
agent  by  which  the  inter-activities  of  these 
vascular  glands  are  affected.  That  group  of 
them  which  promotes  metabolism  has  a  sym- 
pathetic innervation  and  stimulates  the  sym- 
pathetic nerves,  at  the  same  time  exercising 
an  inhibitory  effect  upon  the  autonomous 
nerves.  The  group  which  retards  metabolism, 
on  the  other  hand,  possesses  an  autonomous 
innervation,  and  while  stimulating  the  auto- 
nomous nerves,  inhibits  the  sympathetic. 
The  thyroid  possesses  a  double  function,  being 
furnished  with  both  classes  of  nerves,  and  is 
thus  able  to  affect  both  divisions  of  the  vege- 
tative nervous  system."  It  will  thus  be  seen 
what  an  important  and  central  position  the 
thyroid  holds  in  our  economy,  and  what 
numerous  hints  for  treatment  of  morbid  con- 
ditions and  for  the  explanation  of  them  the 
study  of  the  subject  suggests.  The  great  ab- 
dominal sympathetic  ganglion  has  been  called 
the  Clapham  Junction  of  the  nervous  system. 
In  like  manner  the  thjnroid  seems  to  be  the 
principal  centre  of  the  system,  that  receives 
and  transmits  the  hormonic  and  chalonic 
messages  which  pass  from  gland  to  gland, 
and  which  to  such  a  large  extent  govern 
8 


114     ESSAYS   ON   PRACTICAL   MEDICINE 

the  processes  of  growth  and  nutrition  in  our 
bodies. 

For  practical  reasons  I  think  it  will  be  better 
to  consider  thyroid  insufficiency  or  hypo- 
thyroidism first.  The  external  objective  symp- 
toms of  myxoedema  are  so  marked  that  one 
would  think  the  correct  diagnosis  would  rarely 
be  missed,  but  in  my  experience  this  disease 
is  often  passed  over  or  mistaken  for  Bright's 
disease  ;  if  there  be  any  doubt  as  to  the  nature 
of  the  oedema,  the  examination  of  the  urine  will 
clear  it  up.  It  is  not  my  intention  to  discuss 
the  symptoms  and  treatment  of  complete 
myxoedema,  for  they  are  so  well  known,  but  I 
wish  to  draw  attention  to  the  very  numerous 
cases  of  hypothyroidism  in  which  the  objective 
symptoms  are  not  clearly  marked.  These 
cases  occur  chiefly  in  late  middle  life  and  in 
old  age.  Hertoghe  calls  the  condition  "  Hypo- 
th37roidie  benigne  chronique.''  There  can  be 
no  doubt,  I  think,  that  this  arises  from  partial 
degeneration  of  the  thyroid  and  from  a  lessen- 
ing of  its  colloid  output.  The  symptoms  are 
chiefly  as  follows,  and  show,  I  think,  isolated 
symptoms  of  full  myxoedema.  These  may 
last  for  years,  and  may  never  pass  on,  even  if 
untreated,  into  the  complete  disease.     Shght 


SPECULATIONS  AND   DOUBTS         115 

and  sometimes  transitory  infiltration  of  the  skin 
in  certain  parts  of  the  body  and  in  the  lower 
eyelids  especially  ;  a  common  instance  of  this 
infiltration,  often  unobserved,  is  in  the  lower 
part  of  the  leg  just  above  the  ankles,  and  not 
affecting  the  foot.  This,  if  it  does  not  remain 
pitted  on  pressure  and  if  it  be  not  caused  by 
varicose  veins,  is  almost  a  conclusive  symp- 
tom. The  hair  becomes  thin  and  brittle  and 
loses  its  gloss  and  colour  ;  the  skin  is  generally 
dry  and  harsh  and  the  scalp  shiny  ;  the  tem- 
perature is  subnormal ;  the  hands  and  feet 
are  generally  cold  ;  there  is  a  troublesome 
sense  of  chilliness  over  the  loins  and  upper 
part  of  the  thighs,  which  causes  these  persons 
to  be  very  sensitive  to  draughts  of  air,  and  they 
often  get  catarrhs.  Muscular  pains  about  the 
back  and  even  fibrositis  are  common  and  not 
easily  cured  by  the  ordinary  rheumatic  remedies. 
The  genera]  result  is  low  vitality,  mental  and 
physical,  a  sense  of  chronic  fatigue,  and  a  feel- 
ing of  inability  to  face  the  work  of  life.  In 
most  cases  the  arterial  tension  is  above  nor- 
mal, and  there  are  often  present  the  cerebral 
symptoms  that  go  with  raised  tension,  vertigo 
and  tinnitus.  Women  are  undoubtedly  affected 
more  than  men,  and  if  the  disease  occur  in  them 


ii6    ESSAYS   ON  PRACTICAL   MEDICINE 

before  fifty,  menorrhagia  will  be  common.  If 
there  be  any  doubt  as  to  the  nature  of  these 
cases,  the  judicious  use  of  thyroid  feeding 
will  soon  clear  it  up.  This,  if  done  without 
good  results,  involves  no  risk.  The  disturbed 
rhythm  and  weakness  of  the  heart  caused  by 
thjnroid  should  not  be  a  bar  to  its  use  in  any 
suitable  case.  It  is  only  a  question  of  dose 
or  of  a  counteraction.  Speaking  generally, 
all  these  troubles  can  be  much  relieved  and 
can  often  be  cured  by  th57roid  feeding,  but  the 
treatment  in  most  cases  will  have  to  be  con- 
tinued for  the  rest  of  life.  After  the  symptoms 
have  mostly  passed  away,  five  grains  of  the 
fresh  gland  twice  a  week  is  often  sufficient  to 
maintain  a  fair  degree  of  health.  Not  infre- 
quently we  are  brought  to  what  appears  to  be 
a  deadlock,  by  the  action  of  this  remedy  on  the 
heart.  A  certain  number  of  patients  will  get 
cardiac  pain,  an  irregular  pulse,  and  perhaps 
giddiness  ;  often  they  have  insomnia.  They 
think  they  cannot  go  on  with  the  treatment. 
In  such  cases,  I  believe,  a  low  arterial  tension 
will  be  found,  and  if  so,  suprarenal  extract 
given  at  the  same  time  will  remove  these  dis- 
comforts. Ten  grains  of  suprarenal  and  five 
grains  of  thyroid  daily  will  act  well  together. 


SPECULATIONS   AND   DOUBTS         117 

The  following  is  a  case  in  point.  A  lady, 
aged  fifty-eight,  showed  many  of  the  minor 
symptoms  of  hypothyroidism  ;  and  was  put- 
ting on  weight  so  fast  that  her  breathing 
became  much  embarrassed.  On  five  grains  of 
thyroid  extract  daily,  she  rapidly  lost  weight, 
and  at  first  felt  better.  The  puffiness  of  the 
lower  eyelids  passed  away,  and  her  hair,  which 
originally  had  been  a  bright  auburn,  and  had 
become  dull  and  rusty,  regained  all  its  gloss 
and  colour.  After  three  weeks'  treatment  she 
developed  all  the  cardiac  symptoms  I  have 
enumerated,  and  insomnia.  I  found  her  ten- 
sion 120  mm.  only.  She  took  ten  grains  of 
suprarenal  extract  daily  with  the  thyroid,  and 
all  the  disagreeable  symptoms  passed  away. 

In  all  cases  of  thyroid  treatment,  the 
arterial  tension  should  be  watched,  and  should 
be  the  guide  to  the  increase  or  decrease  of 
the  dose.  When  once  one's  eyes  are  opened,  it 
will  be  surprising  to  find  how  much  hypothy- 
roidism enters  into  the  maladies  of  middle  age. 
Besides  the  symptoms  described,  there  are  also 
occasionally  symptoms  of  profound  nervous 
disorder.  The  following  is  an  instructive  case. 
A  lady,  aged  fifty-six,  whom  I  had  not  seen 
for  some  years,  but  who,  I  think,  had  been 


ii8     ESSAYS   ON   PRACTICAL    MEDICINE 

inclined  to  myxoedema  all  her  life,  collapsed 
suddenly  ;    she  lost  nearly  all  power  over  her 
limbs,  so  that  she  could  not  stand  ;  the  reflexes 
were,  perhaps,  slightly  exaggerated,  but  her 
sphincters  were  for  a  time  quite  paralysed. 
Swallowing  was  not  affected.     She  developed 
very   soon   a   bed-sore,   and  appeared   to   be 
dying  from  prostration  ;    arterial  tension  was 
165  mm.     After  trying  strychnine  for  a  few 
days  without  result,  I  put  her  on  to  thyroid 
feeding  only.     In  a  few  days  her  sphincters 
had  recovered,  the  bed-sore  healed,  and  she 
has  made  a  good  recovery.     Her  friends  say 
that  her  mental  condition  is  better  than  before 
her   illness.     In   this   case   moderate   thyroid 
feeding  will  probably  have  to  go  on  for  years. 
In  women  it  is  especially  about  the  meno- 
pause that  we  shall  find  the  minor  symptoms 
of  hypothyioidism  ;    at  the  same  time  often 
we    shall    find    early    symptoms    of    arterio- 
sclerosis  and   of  high   blood-pressure.     With 
this  knowledge  in  our  minds,  we  ought  to  be 
able  to  steer  many  a  dehcate  woman  safely 
through    these    troublesome    years.     The    in- 
judicious use  of  strong  nerve  tonics  and  of 
nerve  sedatives  in  these  cases  often  does  more 
harm  than  good.    Before  using  them  the  state 


SPECULATIONS   AND   DOUBTS         119 

of  the  thyroid  and  of  the  arteries  should  be 
tested.  In  those  cases  of  hypothyroidism 
where  there  is  subnormal  blood-pressure,  we 
often  find  a  very  poor  state  of  venous  circula- 
tion, as  evidenced  by  cold  feet  and  hands,  with 
the  fingers  and  toes  blue,  and  with  chilblains 
often.  The  vitality  is  generally  low.  Here 
much  benefit  is  obtained  from  the  addition  of 
suprarenal  extract  to  that  of  the  thyroid,  and 
by  giving  freely  calcium  salts.  With  regard 
to  these  calcium  salts  Rendle  Short  says  :  "It 
has  long  been  recognised  that  they  are  essen- 
tial to  the  continued  success  of  perfusion 
fluids,  and  now  we  know  that  they  control 
the  coagulation  and  viscosity  of  the  blood  and 
probably  the  functions  of  the  ovary  and  para- 
thyroid glands  also." 

Remarkable  results  have  been  obtained  in 
many  cases  by  giving  calcium  lactate  in  15- 
grain  doses  three  times  a  day  (on  an  empty 
stomach)  for  three  days  only  in  the  following 
conditions  :  transient  or  functional  albuminuria, 
lymphatic  headache  occurring  in  anaemic  girls, 
in  urticaria,  in  chilblains  and  in  all  varieties  of 
tetany.  The  symptoms  of  the  menopause  are 
sometimes  greatly  relieved  by  this  salt. 

When  one  considers  how  much  the  thj^roid 


I20     ESSAYS   ON   PRACTICAL    MEDICINE 

and  parathyroid  glands  are  concerned  with 
calcium  metabolism,  we  must  realise  how  much 
assistance  they  may  give  in  the  circulatory 
troubles  of  thyroid  disturbance. 

As  we  pass  on  to  real  old  age  we  often  find 
the  symptoms  of  hypoth3^oidism  more  marked 
and  of  graver  import.  We  are  only  beginning 
to  realise  how  much  senility  depends  on  in- 
ternal gland  insufficiency.  Biedl  says  :  "A 
special  pathogenetic  significance  is  ascribed 
to  thyroid  insufficiency  in  the  changes  which 
occur  in  later  life,  and  which  are  included  in 
the  term  senile  degeneration.  The  founda- 
tion for  the  theory  that  old  age  results  from 
changes  in  the  thyroid  gland  lies  in  the  fact 
that  in  old  age  the  thyroid  becomes  atrophied, 
its  follicles  shrink,  and  retrogressive  changes 
take  place  in  the  epithelial  cells.  This  is  re- 
inforced by  the  fact  that  there  is  a  profound 
analogy  between  the  signs  of  advanced  old  age 
and  those  of  myxoedema.  The  falling  of  the 
hair  and  the  dropping  out  of  the  teeth,  the 
dry  and  wrinkled  skin,  the  lowered  body  tem- 
perature, the  diminished  perspiration,  the  in- 
dolent digestion  and  consequent  emaciation, 
the  reduced  metabolism,  the  atrophy  of  the 
sexual  organs,  the  decrease  of    mental  power. 


SPECULATIONS   AND   DOUBTS         121 

and  the   diminution   of  the   activity  of   the 
whole  nervous  system — ^these  are  all  symptoms 
which  characterise  chronic  myxcedema.    Hors- 
ley  holds  the  view  that  senility  is  due,  at  any 
rate  in  part,  to  th5n:oid  degeneration,  while 
myxcedema  may  be  described  as  a  condition 
of  premature  senility/'     Biedl  concludes  by 
saying  :    "  We  have  not  sufficient  grounds  for 
the  assumption  that  senile  decay  results  from 
the  suppression  of  function  of  internal  secre- 
tory   organs    other    than    the    thyroid.     The 
pathogenesis  of  this  condition  offers  a  wide 
field  for   investigation."     With   this   clue   to 
guide  our  researches  and  observations  it  ought 
surely  to  turn  out  a  most  fruitful  field.     The 
mere    prolongation    of    life    were    an    object 
scarcely  worth  the  seeking  if  we  could  not  at 
the  same  time  hope  to  preserve  the  strength  of 
body  and  mind.     There  is  no  pleasanter  sight 
than  old  age  free  from  bodily  suffering  and 
with  mind  serene  and  mature  ;  and  there  is 
no  more  distressing  sight  than  old  age  borne 
down  with  infirmity  and  with  the  mind  clouded 
and  unhappy. 

By  nature  an  incurable  optimist,  I  cannot 
help  thinking  that  these  investigations  and 
discoveries  will  result  in  great  amelioration  of 


122     ESSAYS   ON   PRACTICAL   MEDICINE 

the  troubles  of  senility,  and  in  the  prolonga- 
tion of  healthy  life.  As  an  example  I  give 
the  following  case.  *'  A  man  aged  eighty-five, 
who  for  some  time  had  shown  early  symptoms 
of  brain  degeneration,  suddenly,  after  a  tiring 
day,  collapsed.  He  was  almost  unconscious, 
and  lay  prostrate  on  his  back.  For  days  he 
could  hardly  swallow,  the  power  over  both 
sphincters  was  completely  in  abeyance  ;  bed- 
sore commenced,  and  he  looked  a  hopeless, 
dying  case.  Yet  there  was  no  true  paralysis, 
no  hemiplegia,  no  absolute  aphasia  ;  he  could 
just  move  every  limb  if  pressed  to  do  so. 
Reflexes  were  present,  but  feeble.  Arterial 
tension  was  165  mm.  As  a  forlorn  hope  I 
gave  him  thyroid  extract,  5  grains  daily. 
He  at  once  began  to  improve  ;  in  a  fortnight 
all  incontinence  was  gone,  he  could  swallow 
well,  and  the  bed-sores  promptly  healed. 
After  three  months'  continuous  thj^roid  treat- 
ment he  could  walk  two  miles  daily,  his 
tension  was  down  to  140  mm.  and  his  mental 
condition  was  improved  also.  No  other  medi- 
cinal treatment  was  given,  and  I  think  thyroid 
may  fairly  claim  the  honour  of  the  results.  In 
many  cases  of  bladder  weakness  in  old  age, 
where  there  is  partial  incontinency,  thyroid 


SPECULATIONS   AND   DOUBTS         123 

gives  much  help,  especially  perhaps  after 
paralytic  strokes.  In  old  men  with  enlarged 
prostate  we  see  no  rapid  effects,  but  there  is 
evidence  to  show  that  thyroid  feeding  controls 
and  lessens  the  growth  of  the  gland  itself,  and 
so  in  time  relief  may  come  ;  where  there  is  no 
prostatic  enlargement  and  where  good  results, 
it  must  affect,  I  think,  the  innervation  of  the 
bladder.  When  we  learn  to  use  this  remedy 
more  scientifically  and  in  fitting  doses,  I  feel 
sure  that  we  shall  have  far  more  control  over 
the  maladies  of  old  age,  and  over  some  of  their 
mental  disabilities  also. 

In  childhood  there  is  also  a  large  field  for  its 

use.     In  the  enuresis  of  children  and  young 

adults  thyroid  rarely  fails  to  cure,  but  in  some 

cases  enuresis  is  caused  by  it  or  increased. 

It  is  well  borne  in  youth,  and  seldom  produces 

the  distressing  cardiac  symptoms  that  we  find 

later  in  life  ;    even  in  infants  it  can  be  given 

safely  and  with  good  results — -for  instance,  in 

some  cases  of  infantile  eczema.  There  is  a  great 

opportunity  for  its  use,  I  feel  sure,  in  cases  of 

arrested  development  both  of  mind  and  body. 

In  childhood  we  occasionally  see  two  types  of 

myxoedema  ;   one  congenital,  showing  itself  in 

infancy,  and  not  due  to  disease,  but  to  entire 


124     ESSAYS   ON   PRACTICAL    MEDICINE 

absence  of  the  thyroid.  These  cases  resemble 
in  their  symptoms  those  in  which  the  thyroid 
has  been  entirely  removed  ;  they  are  very 
severe,  and  are  accompanied  always  by  dwarf- 
ism and  idiocy  ;  in  these  little  but  temporary 
good  can  be  expected.  The  other  type — 
called  not  very  happily  infantile  myxoedema — 
shows  itself  about  the  fifth  year.  It  is  much 
like  adult  myxoedema,  and  is  clearly  due  to 
atrophy  of  a  thyroid  gland  that  has  been 
present.  Here  thyroid  treatment  may  do 
much  good  and  even  wake  up  the  atrophied 
gland  to  new  life. 

Hypothyroidism  is  probably  the  foundation 
of  the  condition  known  as  infantilism,  the  chief 
features  of  which  are  the  persistence  of  infantile 
characteristics  in  mind  and  body.  The  above 
three  morbid  conditions  show  the  extreme 
results  of  athyroidism  and  of  hypothyroidism, 
but  there  are  innumerable  cases,  most  of  them 
unrecognised,  in  which  partial  and  often  tem- 
porary arrest  of  mental  and  bodily  develop- 
ment is  caused  by  thyroid  deficiency.  There 
can  be  no  doubt  that  the  healthy  state  of  this 
gland,  in  conjunction  with  the  pituitary,  is 
very  largely  responsible  for  normal  growth 
and  development.    In  watching  the  growth  of 


SPECULATIONS  AND   DOUBTS        125 

a  young  animal,  a  colt,  for  instance,  we  see  him 
at  one  time — -to  use  a  slang  expression — all  legs 
and  no  head,  in  another  month  or  so  he  is  all 
head  and  no  legs.  Growth  and  development, 
mental  and  bodily,  even  in  healthy  children, 
seem  often  to  progress  in  jerks.  It  is  in  these 
cases  that  the  judicious  use  of  thyroid  and 
sometimes  of  pituitary  extract  will  often  tide 
over  difficulties.  A  wise  schoolmaster  or  mis- 
tress should,  if  the  circumstances  and  theories 
be  explained  to  them,  be  a  very  good  judge  of 
the  need  of  thyroid  and  of  its  value.  Many  an 
apparently  hopeless  child  will  wake  up  into 
mental  activity  under  its  use. 

In  young  girls  at  the  age  of  puberty  or  soon 
after,  in  whom  there  is  amenorrhoea  or  dysmen- 
orrhoea  (not  due  to  some  mechanical  cause) 
it  will  often  put  everything  right.  It  will 
be  no  exaggeration,  I  think,  to  say  that  in 
amenorrhoea,  not  obviously  due  to  chlorosis, 
thyroid  is  the  most  successful  remedy.  Further 
— -which  is  a  very  important  matter  for  the 
future  of  every  woman — -it  promotes  complete 
and  healthy  development  of  the  whole  sexual 
apparatus.  In  mental  disease,  especially  in 
asylum  practice,  where  the  symptoms  can  be 
carefully  watched,   I  feel  sure  that  internal 


126    ESSAYS   ON  PRACTICAL   MEDICINE 

gland  remedies  will  show  very  happy  results. 
The  variations  of  arterial  tension  from  the 
normal  that  occur  in  melancholia,  where  the 
tension  is  often  very  high,  and  in  acute 
maniacal  conditions,  where  after  the  attack  it 
is  very  low,  can  often  be  corrected  by  the  care- 
ful use  of  thyroid,  suprarenal  or  other  gland 
extracts. 

Another  use  of  thyroid  which  holds  out  great 
promise  of  success  is  in  albuminuria  and  threat- 
ening eclampsia  of  pregnancy. 

In  this  morbid  state  we  see  constantly  raised 
blood- pressure,  albumin  and  diminished  secre- 
tion of  urea.  The  secretion  of  urine,  in  a  bad 
case,  almost  entirely  ceases,  and  if  any  is  passed 
it  boils  almost  solid.  The  more  threatening 
the  symptoms,  the  higher  the  blood-pressure 
rises.  If  the  patient  is  put  to  rest  in  bed  and 
a  careful  diet  of  milk  and  farinas  only  given, 
thyroid  will  generally  ward  off  the  danger  of 
eclampsia  ;  but  full  doses  must  be  given — a 
5-grain  tablet  of  fresh  extract  every  three  or 
four  hours.  This  in  twenty-four  hours  will 
produce  a  free  flow  of  urine,  with  increased  urea 
and  lessened  albumin.  As  the  symptoms  im- 
prove the  doses  must  be  lessened,  but  thyroid 
treatment   should  be   continued  till  delivery 


SPECULATIONS  AND   DOUBTS         127 

takes  place  and  for  a  time  afterwards.  This 
treatment  was  first  suggested  by  Dr.  Oliphant 
Nicholson  of  Edinburgh  in  1901.  The  follow- 
ing interesting  cases  have  occurred  lately  in  the 
practice  of  my  son,  Dr.  Arthur  Scott  : 

(i)  A  woman  aged  twenty-six  became 
albuminuric,  with  marked  oedema,  when  be- 
tween five  and  six  months  pregnant;  about 
the  thirtieth  week  fits  started,  recurring  every 
few  minutes  :  labour  had  not  started.  She  was 
given  10  grains  of  the  fresh  thyroid  three  times 
a  day,  and  was  put  into  hot  packs.  After  eight 
hours  fits  ceased,  and  the  urine  became  copious, 
though  before  only  a  few  ounces  had  been 
secreted  in  the  twenty-four  hours.  Labour 
was  induced  two  days  later  ;  the  child  died 
two  days  after  birth  in  convulsions. 

(2)  A  woman  aged  thirty-four  started  oedema 
and  albuminuria  about  the  eighth  month. 
Urine  passed  in  twenty-four  hours  was  6  ozs. 
only,  and  boiled  solid  with  albumin.  (Edema 
became  general :  8  grains  of  fresh  thyroid  were 
given  three  times  daily  and  a  daily  hot  pack. 
Urine  at  once  became  plentiful  and  oedema 
lessened.  She  went  her  full  time,  taking  17 
grains  a  day  :  parturition  was  normal  without 
eclampsia.     The  child  died  in  convulsions  three 


128     ESSAYS  ON   PRACTICAL   MEDICINE 

days  later,  though  apparently  healthy  at 
birth. 

(3)  Woman  aged  twenty-eight.  Albuminuria 
and  oedema  came  on  suddenly  when  about  a 
fortnight  from  full  time.  Urine  passed  in 
twenty-four  hours  only  4  ozs.  (Edema  great, 
with  much  dyspnoea.  Patient  was  seen  at 
night,  and  30  grains  of  fresh  gland  was  given 
in  the  first  twelve  hours,  and  then  reduced  to 
20  grains  in  twenty-four  hours.  Under  this 
thyroid  treatment  and  without  any  hot  packs 
improvement  at  once  set  in,  oedema  and 
dyspnoea  diminished,  and  the  urine,  though  still 
loaded  with  albumin,  increased  to  30  ozs. 
Parturition  was  normal  and  the  child  survived. 
In  this  case  thyroid  was  given  to  the  child 
at  once,  and  there  were  no  convulsions. 

This  remedial  effect  is  not  easy  to  explain. 
The  thyroid,  no  doubt,  in  these  large  doses 
lowers  the  blood-pressure  considerably,  but 
that  will  hardly  explain  its  diuretic  action. 
It  must  act,  I  think,  favourably  on  the  ovaries 
and  possibly  on  the  suprarenals.  The  occur- 
rence of  fits  in  the  new-born  infants  seems 
more  than  a  coincidence. 

Not  unfrequently  in  girls  from  twelve  to 
eighteen  years  of  age  we  see  an  enlargement  of 


SPECULATIONS  AND  DOUBTS         129 

the  thyroid,  which  comes  on  rather  suddenly. 
The  gland  feels  pulpy  and  as  a  rule  is  not 
painful,  but  it  often  interferes  with  swallowing 
by  its  backward  growth.  There  is  no  marked 
pulsation  and  no  tachycardia.  This  enlarge- 
ment soon  subsides  with  thjnroid  feeding  and 
can  be  cured,  but  if  the  cause  be  not  recog- 
nised a  permanent  enlargement  and  deformity 
remains.  After  twenty  the  symptoms  of  sub- 
th5n:oidism  usually  disappear. 

There  has  been  some  confusion  and  doubt 
as  to  dosage  of  gland  extracts,  some  physi- 
cians and  writers  working  with  fresh-gland 
tablets  and  some  with  dried  powders.  It  will, 
I  think,  be  a  help  if  I  give  the  following  rela- 
tions, which  are  approximately  correct : 

British  Pharmacopceia 
I  grain  of  dried  thyroid  =  3 1  grains  of  fresh  gland. 

Dried  Powders  of  Various  Makers 
I  grain  dried  orchilic  =  7  grains  fresh  gland. 
I  grain  dried  whole  pituitary  =  4  grains  fresh  gland, 
I  grain  dried  ovarian  =  7  grains  fresh  gland. 
I  grain  dried  suprarenal  =  6  grains  fresh  gland. 
I  grain  dried  pitglandin  or  ant.  pituitary  =  4  grains  of 
fresh  gland. 

The  following  is  an  extract  from  Dr.  Ken- 
dall's article  in  Endocrinology : 

"  Plummer  has  been  making  a  very  detailed 

9 


130     ESSAYS  ON   PRACTICAL   MEDICINE 

study  of  the  function  of  the  thj^oid,  and  he 
has  been  led  to  believe  that  the  location  of 
the  active  constituent  of  the  thjnroid,  when  it 
functions,  is  within  the  cells,  not  of  any  par- 
ticular set  of  organs  or  portion  of  the  body, 
but  that  it  is  a  constituent  of  cellular  life  and 
activity.  He  says  that  this  active  constituent 
of  the  thyroid  determines  the  rate  at  which  any 
particular  cell  can  produce  energy — that  is,  it 
establishes  the  quantum  of  energy  which  any 
cell  can  produce  when  it  is  stimulated  either 
from  within  itself  or  from  without — so  that  the 
thyroid  is  directly  related  to  the  production  of 
energy  within  the  body.  He  has  found  that 
one-third  of  one  milligram  of  the  active  con- 
stituent increases  the  basal  metabolic  rate 
I  per  cent,  in  an  adult  150  lbs.  in  weight. 

*'  When  the  active  constituent,  thyroxin, 
is  given  to  a  myxoedematous  patient,  all  the 
sjnuptoms  are  promptly  reheved  ;  when  it  is 
given  in  too  large  a  dose,  hyperthyroid  symp- 
toms are  produced.  The  moment  we  know  that 
in  a  myxoedematous  patient  the  administration 
of  10  mg.  of  thyroxin  increases  the  basal  meta- 
boHc  rate  30  per  cent.,  we  have  the  key  to  the 
explanation  of  the  relief  of  a  very  complicated 
clinical  syndrome. 


SPECULATIONS  AND   DOUBTS         131 

"  The  oedema  is  relieved,  the  sluggish 
mentality  is  relieved,  and  all  the  symptoms 
disappear.  In  short,  every  cell  in  the  body 
responds  with  its  own  expression  of  activity." 

This  increased  cellular  and  metabolic  activity 
suggests  many  uses  of  thyroid  in  other  con- 
ditions than  of  pure  myxoedema  and  gives  a 
scientific  basis  and  direction  for  its  use  in 
disease. 

Graves'  disease  is  of  all  the  endocrine  dis- 
turbances the  most  puzzling,  and  in  consequence 
perhaps  the  most  interesting.  I  prefer  to  still 
use  the  name  of  the  great  physician  who  first 
described  it,  for  the  modern  title  Exophthalmic 
Goitre  is  neither  accurate  nor  inclusive  of  all 
the  symptoms.  On  this  subject  I  am  quoting 
largely  from  an  article  of  mine  in  the  Practi- 
tioner of  May  1 918,  which  its  Editor  has  most 
kindly  given  me  leave  to  use. 

The  cardinal  symptoms  of  Graves'  disease 
are  thyroid  enlargement,  exophthalmos,  tachy- 
cardia and  nervous  tremor  ;  but  the  first  two 
may  be  entirely  absent,  while  the  last  two 
are  always  present.  In  this  disease,  perhaps, 
more  than  in  most,  the  prominent  symptoms 
are  generally  so  striking  that  the  unscientific 
mind  sees  the  superficial  picture  only,   the 


132     ESSAYS   ON  PRACTICAL   MEDICINE 

visible  morbid  signs,  and  contentedly  sees  no 
more. 

In  reality  this  syndrome  displays  a  wonder- 
ful example  of  deep-seated,  widely- distributed 
functional  disturbance,  that,  if  unchecked,  ends 
in  organic  structural  disease.  The  cause  is 
neither  in  the  thyroid  nor  in  the  eye.  When 
one  studies  the  early  history  of  these  cases 
and  their  premonitory  signs,  one  is  inevitably 
led  back  to  the  nervous  system,  and  especially 
to  the  sympathetic  branch  of  that  system. 
The  tremor  and  the  tachycardia,  which,  as  I 
have  said,  are  always  present,  precede  the 
thjnroid  enlargement  and  the  exophthalmos. 
This,  I  think,  proves  that  the  nervous  system 
is  the  functional  disturbance  that  comes  before 
the  more  visible  signs  ;  but  we  must  go  still 
deeper  and  search  for  the  causa  causans. 
In  some  cases,  especially  in  women,  but  not 
exclusively,  there  is  a  clear  account  of  nervous 
shock,  of  great  grief  or  anxiety  sufficient 
perhaps  to  be  called  a  cause,  but  in  some 
cases  the  oncoming  is  insidious,  and  there  is  a 
period  when  there  is  no  th5Toid  enlargement, 
and  only  occasional  tachycardia  and  tremor; 
and  even  in  the  shock  cases  careful  inquiry 
will  often  reveal  pre-existing  disorder. 


SPECULATIONS  AND   DOUBTS         133 

McGarrison's  definition  is  this  : 

"  A  disease  characterised  by  heightened  ex- 
citability of  the  whole  sympathetic  nervous 
system,  greatly  increased  metabolism,  abnormal 
action  of  the  heart  and  of  the  thyroid  gland, 
and  disordered  states  of  other  hormone  pro- 
ducing organs." 

It  is  very  rare  before  the  age  of  puberty.  It 
occurs  in  women  much  more  frequently  than 
in  men,  and  in  them  is  almost  entirely  confined 
to  the  years  of  their  sexual  activity.  In  men  it 
not  infrequently  occurs  in  later  life.  It  ter- 
minates in  recovery,  death  or  myxcedema. 

I  cannot,  for  my  purpose,  do  better  than 
quote  Major  McGarrison's  exhaustive  descrip- 
tion.    He  says  : 

**  The  setiological  factors  which  favour  the 
onset  of  Graves'  disease  are  those  which  we 
have  seen  determine  all  departures  of  the 
thyro-parathyroid  glands  from  the  normal 
state ;  these  are  nutritional,  psychic  and 
infectious. 

"  Briefly  recapitulated,  these  factors  are  : 
(i)  insufficient  food  or  over-indulgence  in  food, 
and  the  disorders  of  nutrition  to  which  these 
and  chronic  debilitating  diseases  give  rise. 
Amongst  the  most  important  of  such  diseases 


134     ESSAYS  ON  PRACTICAL    MEDICINE 

are  chronic  constipation,  intestinal  disorders 
generally,  and  chiefly  intestinal  stasis.  (2) 
Fright,  mental  distress  and  worry,  business  or 
social  cares,  unfortunate  love-affairs,  violent 
emotion,  and  mental  and  physical  exhaustion, 
with  loss  of  sleep,  such  as  occurs  amongst 
soldiers  in  the  trenches.  (3)  Attacks  of  acute 
infectious  diseases,  notably  influenza,  tonsilitis, 
rheumatic  fever,  typhoid  fever,  tuberculosis, 
secondary  or  hereditary  syphilis;  naso-pha- 
ryngeal  and  uro-genital  disorders,  pyorrhoea 
alveolaris  and  helminthiasis. 

"  As  in  myxoedema,  so  in  Graves'  disease,  the 
onset  of  a  proportion  of  cases  may  be  precipi- 
tated by  some  accidental  occurrence,  such  as 
a  train  disaster,  a  fall  from  a  horse,  or  by  the 
excitement  and  strain  of  war. 

'*  The  ideal  conditions  for  the  development 
of  the  disease  are  provided  when  all  three  classes 
of  factors — nutritional,  psychic  and  infectious 
— operate  on  the  individual  at  the  same  time, 
or  where  two  of  them  do  so.  They  a  e  pre- 
disposing causes  only,  which  favour  the  action 
of  the  underlying  causal  agency. 

"  This  agency  is  one  which  gives  rise  to 
continuous  excitation  of  the  sympathetic 
nervous  system.     That  symptoms  similar  to 


SPECULATIONS   AND   DOUBTS         135 

those  of  exophthalmic  goitre  can  be  induced 
by  the  continuous  excitation  of  this  system 
is  shown  by  the  experiment  of  Cannon,  where 
the  phrenic  nerve  was  joined  to  the  peripheral 
portion  of  the  cut  cervical  sympathetic  in  the 
cat  (Cannon,  W.  B.,  Boston  Medical  Journal, 
1916,  clxxv.  16,  p.  564).  The  operation 
resulted  in  tachycardia,  increased  excitability, 
loose  motions,  exophthalmos,  on  the  operated 
side,  and  increase  of  the  body  metabolism,  as 
well  as  in  an  increase  in  the  size  of  the  adrenals. 
In  seeking  for  the  source  of  the  excitant  of  these 
symptoms  in  Graves'  disease,  one  is  reminded 
that  effects  similar  to  those  caused  by  stimula- 
tion of  the  sympathetic  nervous  system  are 
produced  by  certain  amines,  resulting  from 
the  putrefactive  decomposition  of  proteins  or 
amino-acids  in  consequence  of  bacterial  action 
(Barger,  G.,  *  The  Simpler  Natural  Bases,' 
London,  1914).  The  most  common  source  of 
these  amines  is  the  gastro-intestinal  tract. 

"  The  extraordinary  influence  of  the  gastro- 
intestinal toxaemia  in  the  genesis  of  Graves* 
disease  is  exemplified  by  a  case  recently  ad- 
mitted under  the  care  of  Sir  Arbuthnot  Lane 
at  Guy's  Hospital. 

"  The  subject  was  a  girl  of  ig^-  years  of  age^ 


136     ESSAYS  ON  PRACTICAL   MEDICINE 

who  developed,  in  South  Africa,  Graves'  disease 
of  very  severe  type.  The  condition  was  of  some 
eighteen  months'  standing.  She  had  a  marked 
rheumatic  history,  having  had  chorea  at  nine 
years,  and  '  nervous  debiUty '  for  six  months 
at  thirteen  years.  She  had  suffered  from 
palpitation  from  the  age  of  eleven.  On  ad- 
mission to  hospital  she  presented  the  following 
sjmiptoms  :  great  emaciation,  dull  abdominal 
pain,  recurring  attacks  of  nausea  and  vomiting, 
goitre  of  small  size,  prominent  exophthalmos, 
tachycardia,  severe  palpitation  and  a  heart's 
action  so  violent  as  to  shake  the  bed,  great 
pulsation  of  the  carotids,  abdominal  and  iliac 
arteries,  great  muscular  weakness,  pronounced 
tremor  with  a  tendency  to  drop  things,  great 
nervousness,  dizziness,  severe  headache,  flush- 
ings, subjective  sensations  of  heat,  suppressed 
menses,  loss  of  and  greying  of  the  hair,  vora- 
cious appetite,  and  albumen  and  sugar  in 
the  urine  ;  in  short,  a  case  so  typical  and  so 
severe  as  to  leave  no  room  for  doubt  as  to 
its  nature. 

''  Rontgen-ray  examination  by  Dr.  Jordan 
revealed  the  presence  of  a  greatly  dilated 
stomach  with  pyloric  spasm,  an  elongated 
duodenum,  and  a  state  of  chronic  irritation  of 


SPECULATIONS  AND   DOUBTS         137 

the  colon,  resulting  in  unduly  rapid  emptying 
of  the  contents. 

**  Sir    Arbuthnot    Lane    performed   gastro- 
jejunostomy, and  removed  an  anchored  appen- 
dix, which  exerted  a  most  marked  control  upon 
the  ileal  effluent,  and  freed  a  very  tight  ter- 
minal kink  at  the  junction  of  the  ileac  and 
pelvic  colon.     The  operation  was  performed 
on  January  21,  1916,  and  was  followed  by  two 
weeks'   considerable    pyrexia.     At  this    time 
the  patient's  weight  was  only  4  st.  10  lbs.,  but, 
following  the  return  of  the  temperature  to 
normal,  she  began  to  put  on  weight  and  to 
improve  in  the  most  remarkable  way.     Seen 
on  October  20,  1916,  her  weight  had  increased 
to  8  St.  5  lbs.,  the  exophthalmos  had  totally 
disappeared,   the   palpitation  was  completely 
gone  and  the  tachycardia  was  greatly  lessened, 
menstruation  had  returned,  the  muscular  weak- 
ness, headache,  vomiting    and  all  the  other 
symptoms,  with  the  exception  of  the  small 
goitre,  had  disappeared.     The  goitre  was  but 
little  altered  in  size,  and  persisted,  doubtless, 
owing  to  fibrotic  changes.     The  patient  felt 
and  looked  a  different  being,  and  could  walk 
for  a  considerable  distance  without  fatigue, 
while  the  greyness  of  the  hair  had  disappeared 


138     ESSAYS   ON   PRACTICAL   MEDICINE 

and  its  scantiness  was  replaced  by  luxuriant 
growth. 

"  Here,  then,  is  a  case  of  surpassing  interest, 
in  which  the  symptoms  of  Graves'  disease  are 
definitely  shown  to  have  resulted  from  alimen- 
tary toxaemia." 

There  are  many  other  cases  reported  in 
which  intestinal  stasis,  gastro-enteroptosis  and 
chronic  colitis  have  for  a  long  time  preceded 
true  Graves'  disease,  and  in  which  all  s^^mptoms, 
except  thyroid  enlargement,  have  passed  off 
after  cure  of  the  abdominal  fault. 

Skilled  X-ray  examination  of  the  abdomen 
will  often  reveal  a  removable  cause  of  septic 
absorption. 

McGarrison  says  further  on :  "  The  thyroid 
gland  has  for  so  long  played  the  star  part 
in  the  drama  of  Graves'  disease,  that  too 
little  attention  has  been  paid  to  less  promi- 
nent performers,  and  its  author's  identity 
has  for  this  reason  been  to  a  great  extent 
obscured." 

Other  sources  of  microbic  infection  may  be 
found  in  the  gums,  tonsils  or  nose  (pyorrhoea 
alveolaris  is  common  in  this  state),  and  finally 
a  microscopic  examination  of  the  faeces  may 
show  an  abdoniinal  bacterial  content,  to  which 


SPECULATIONS  AND   DOUBTS         139 

the  patient's  resistance  is  low,  and  which  might 
possibly  form  a  curative  vaccine. 

The  anatomical  alterations  found  in  many 
organs  would  take  too  long  to  describe  in  a 
book  of  this  description  ;  for  these  I  must  refer 
to  text-books,  and  especially  to  McGarrison's 
great  work  on  the  Thyroid  Gland. 

From  the  general  practitioner's  point  of  view, 
which  is  also  mine,  in  all  the  academic  text- 
book descriptions  of  disease  there  is  something 
lacking.  It  is,  no  doubt,  interesting,  and  to  a 
certain  extent  satisfactory,  to  find  a  diagnosis 
confirmed  in  the  post-mortem  room,  but 
nevertheless  that  room  remains  the  grave  of 
our  hopes,  the  mausoleum  of  our  failures.  In 
the  words  of  "The  Biglow  Papers*'  : 

"  Sermon  through  and  come  to  do — 
Why,  there's  the  old  J.  B. 
A-crowdin'  you  and  me." 

John  Bull  and  his  daughters  have,  in  their 
blind,  rather  selfish  way,  no  altruistic  ambitions 
to  become  pathological  specimens  ;  they  want 
to  be  cured,  and  it  is  we  general  practitioners 
that  have  to  do  it.  ^Etiology,  morbid  anatomy, 
family  histories  and  predisposing  causes  are 
all  very  valuable  in  their  way,  but  the  study  of 
disease  is  too  apt  to  end  here  ;    they  are  all 


I40     ESSAYS   ON   PRACTICAL   MEDICINE 

useless,  unless  they  are  made  the  sure  and 
stable  foundations  for  building  thereon  the 
temple  of  health. 

Graves'  disease  in  a  hospital  ward  is  a  very 
interesting  study,  but  in  domestic  life  it  is 
almost  a  tragedy  ;  the  nervous  restlessness, 
irritability  and  unreasoning  temper  become 
a  scourge  both  to  the  patient  and  to  the  family. 
One  cannot  help  feeling  that  up  to  recent  times 
the  treatment  of  this  disease  has  been  almost 
a  failure.  About  half  the  number  recovered 
more  or  less  spontaneously,  more  or  less  com- 
pletely, and  the  other  half  went  down  the  hill 
and  died. 

The  greatly  increased  metaboHsm  leads  to 
emaciation,  dilatation  of  the  heart  and  valvular 
insufficiency.  The  treatment  to-day,  with  our 
new  and  rapidly  increasing  knowledge  of  the 
endocrine  glands,  is  much  more  hopeful  and 
already  more  successful.  Briefly,  not  wishing 
to  be  dogmatic,  but  only  suggestive,  this,  I 
think,  should  be  the  scheme.  First,  rest,  as 
complete  as  circumstances  and  the  tempera- 
ment of  the  patient  will  allow — it  will  never 
be  more  than  partial ;  secondly,  find  out  by 
all  the  means  in  our  power  the  initial  error, 
the  source  of  microbic  infection,  if  such  there 


SPECULATIONS  AND   DOUBTS         141 


be,  intestinal,  uterine,  oral,  nasal;  then 
medically  or  surgically  treat  them  as  they  need, 
and  finally  treat  the  resulting  symptoms  by 
our  modern  glandular  extracts. 

In  practice,  all  these  methods  will  have  to 
be  carried  out  together.  The  first  error  to  be 
attacked  in  the  majority  of  cases  will  be  in  the 
digestive  tract ;  frequently  there  will  be  found 
gastric  or  intestinal  dyspepsia,  and  the  intes- 
tinal is  the  more  important ;  signs  of  coHtis 
are  often  present.  These  faults  are  best 
attacked  by  intestinal  antiseptics,  such  as 
beta-naphthal  and  saHcylate  of  bismuth.  In 
addition  to  these  duodenal  extract  is  a  great 
help. 

This  formula  I  have  found  work  well : 

Duodenal  Extract  ....     grs.  2 

Ext,  Cannabis  Ind.        .  .  •  •     gr.    | 

In  tablets  :  one,  three  times  a  day,  an  hour  after  food. 

This  acts  often  like  a  charm  on  duodenal 
catarrh  and  on  colitis  that  has  not  gone  too  far. 
Carnrick's  new  Kinazyme  acts  very  favourably 
in  the  same  way.  Constipation  can  generally 
be  avoided  by  giving  paraffin  daily.  The  diet 
should  be  simple,  not  rich,  and  should  not 
include  much  meat.  Milk  better  than  any  other 
food  supplies  the  waste  of  lime  salts. 


142     ESSAYS  ON  PRACTICAL   MEDICINE 

The  persistent  diarrhoea  which  one  sees  in 
a  few  cases  will  nearly  always  yield  to  the 
following  : 


Bism 

uth.  Salicylat.    . 

. 

grs. 

12 

Liq. 

Hyd.  Perchlor.  . 

. 

ni3 

Pulv 

Trag.  Co, 

. 

q.s. 

Tine. 

Chloroform.  Co. 

c,  Morph. 

(P.B. 

1885)     . 

. 

11^12 

ter  die 

The  small  dose  of  the  perchloride  with  the 
salicylate  acts  well  as  a  bactericide. 

There  is  one  gland  which  is  grossly  affected 
in  the  disease  besides  the  thyroid,  and  that  is 
the  thymus.  In  about  75  per  cent,  of  cases 
this  has  been  found  much  enlarged.  It  would 
seem  that  the  enlargement  does  not  mean 
increase  of  function,  but  the  opposite,  for  in 
some  few  cases  thymus  feeding  has  had  very 
good  results.  It  fails  in  the  majority,  I  think, 
and  how  to  select  the  likely  cases  I  know  not. 

When  we  come  to  the  special  symptoms  of 
Graves'  disease,  we  must  decide  whether  to 
attack  the  cardiac  or  the  nerve  symptoms 
chiefly,  though  both  may  be  treated  to  a 
certain  extent  together. 

The  original  cause  acts  probably  as  a  dis- 
turber of  all  internal  glands,  but  the  three 
chiefly  affected  are  the  suprarenal,  the  thyroid 


SPECULATIONS  AND   DOUBTS         143 

and  the  parathyroid.  The  suprarenal  is  sup- 
posed to  be  over-stimulated  by  the  excess  of 
thyrine  poured  into  the  blood,  which  is  known 
to  be  a  hormone  to  that  organ,  but  it  may  be 
affected  primarily  by  the  same  poison.  In 
most  cases,  then,  we  get  evidence  of  thyroid 
and  suprarenal  excess.  The  exophthalmos  is 
due  to  excessive  action  of  the  suprarenals,  as 
has  been  shown  by  Maurice  of  Lyons.  The 
tachycardia  is  generally  the  earliest  symptom 
that  we  can  estimate,  and  is  due  to  irritation  of 
the  sympathetic  nerves  supplying  the  heart. 

McGarrison  says,  p.  213  : 

**  It  does  not  appear  from  evidence  at  present 
available  that  the  explanation  of  the  cardiac 
activity  is  so  superficial  or  simple  as  either  a 
thyroid  hypersecretion  or  hyposecretion  would 
indicate,  but  both  the  cardiac  activity  and  the 
thyroid  reaction  are  parallel  manifestations, 
consequent  on  some  more  general  and  remote 
disturbances. 

"  Not  only  does  the  thyroid  hyperplasia  bear 
no  direct  relationship  to  the  pulse-rate,  but  the 
excess  of  a-iodine  (thyroid  hormone)  in  the 
blood-stream,  which  results  from  it,  appears  to 
be  only  indirectly  responsible  for  the  tachy- 
cardia.   Experiment  has  shown  that  after  the 


144     ESSAYS   ON  PRACTICAL   MEDICINE 

administration  of  this  substance  there  is  no 
apparent  effect  for  many  hours.  There  is  no 
increased  pulse-rate  or  drop  in  the  blood- 
pressure.  If,  however,  amino-acids  are  injected 
simultaneously  the  pulse-rate  is  enormously 
increased  (Kendal,  E.  C,  Boston  Medical  and 
Scientific  Journal,  1 916) .  These  findings  appear 
to  me  to  provide  a  further  clue  to  the  nature  of 
the  substances  responsible  for  the  heightened 
cardiac  action  in  Graves'  disease.  They  are, 
I  beheve,  the  poisonous  decomposition  product 
of  amino-acids — 'monamines  and  diamines — 
which  may  be  formed  in  the  organism  wherever 
proteins  or  amino-acids  are  exposed  to  the 
action  of  bacteria,  and  especially  to  the  action 
of  anaerobic  bacteria  in  the  gastro-intestinal 
tract  (Barger,  G.,  **  The  Simpler  Natural 
Bases,''  London,  1914).  These  highly  virulent 
poisons  may  not  only  initiate  the  histological 
changes  in  the  thyroid  gland,  but,  by  their 
direct  action  on  the  adrenal  sympathetic  system 
or  by  their  chemical  interaction  with  the 
gland's  secretion  and  the  disturbance  of  its 
normal  balance,  they  may  give  rise  at  the  same 
time  to  the  tachycardia." 

Man  is  much  more  susceptible  to  large  doses 
of  thyroid  than  animals,  but  although  some  of 


SPECULATIONS  AND   DOUBTS         145 

the  symptoms  of  Graves'  disease  are  produced 
by  these  doses  the  whole  picture  or  syndrome 
is  iar  from  complete. 

We  must,  I  think,  conclude  that  hypersecre- 
tion of  the  thyroid  is  only  one  of  the  causes  of 
the  cardiac  affection. 

There  arises  now  the  question  :  How  much 
is  the  parathyroid  involved  ?  The  nerve 
tremors  point  to  parathyroid  deficiency.  Does 
the  cause  that  stimulates  the  suprarenal  and 
the  thyroid  depress  parathyroid  action  ?  Or  is 
the  balance  of  power  so  disturbed  that  the 
excess  of  thyrine  overwhelms  the  parathyroid  ? 
I  think  the  latter  is  probably  the  case.  The 
nervous  symptoms  point,  as  I  have  said,  to 
parathyroid  deficiency,  but  this  may  be  only 
relative  ;  the  natural  antagonism  between  the 
two  glands  is  always  present,  but  the  hyper- 
thyroidism wins  the  day.  It  will  be  found,  I 
think,  that  parathyroid  treatment  by  the  mouth 
controls  and  helps  much  to  cure  the  tremors  and 
other  nerve  troubles  of  this  disease.  I  have 
seen  this  case  lately  : 

A  lady,  thirty-two  years  of  age,  had  had 
colitis  and  leucorrhoea  for  some  time,  and  latter- 
ly an  ulcerated  condition  of  tongue  and  mouth  ; 
she  had  lost  flesh,  and  become  very  weak  and 
10 


146     ESSAYS   ON   PRACTICAL   MEDICINE 

short  of  breath.  She  had  tachycardia,  varying 
in  intensity,  and  characteristic  tremors  of  the 
hands.  The  th3n:oid  was  sHghtly  enlarged  and 
pulsating — no  exophthalmos;  the  stethoscope 
revealed  a  slight  systolic  murmur  over  the 
gland.  She  was  given  Izal  perles  and  para- 
thyroid (dried)  in  J-grain  doses  three  times  a 
day. 

This  is  a  typical  case  of  Graves'  disease  with 
the  common  intestinal  causation.  Four  weeks 
of  this  treatment  has  removed  all  the  symp- 
toms, with  the  exception  of  the  colitis,  which  is 
not  quite  cured. 

Another  type  of  case  of  early  Graves',  the 

most  acute  I  have  ever  seen,  has  been  published 

in  the   Practitioner,  but  will,   I  think,  bear 

repeating.     It  was  reported  by  Dr.  Norman  of 

Broadstone. 
A  young  woman  miscarried  at  four  months 

on  May  3,    1915 — no  abnormal  hsemorrhage. 

At  the  same  time   she  complained  of  such 

intense  headache  that  all  other   pains  were 

masked. 

May  6. — 'Slight  dyspnoea,  temp.  100.     Has 

not  slept  since  her  illness  began  ;    headache 

still  very  bad,  pulse  no. 

May  14. — I  saw  the  case  with  Dr.  Norman. 


SPECULATIONS  AND   DOUBTS         147 

Pulse  130.  Systolic  pressure  100  mm.,  with 
large  pulsating  thyroid,  heart  dilated,  great 
dyspnoea,  tremor  of  hands,  but  no  exoph- 
thalmos. She  was  quite  unable  to  lie  down, 
and  looked  as  if  she  had  only  a  day  or  two  to 
live.  Diagnosis,  acute  Graves'  disease.  That 
night  she  slept  after  scopolamine  and  morphia. 
Parath5^oid,  |~gr.  doses,  was  given  frequently, 
and  in  four  days  all  symptoms  rapidly  abated. 
On  the  25th — ^eleven  days  after  parathyroid 
was  begun — -she  was  able  to  be  about,  the 
thyroid  enlargement  had  almost  disappeared, 
and  she  has  continued  quite  well  ever  since, 
more  than  a  year  having  elapsed. 

In  this  case,  there  was  no  evident  sepsis  in 
the  mother,  and  the  cause  was  possibly  in  the 
dead  foetus. 

The  only  exogenous  drug  that  seems  to  me 
to  be  of  use  is  strophanthus  ;  this  may  be  given 
in  large  doses  when  the  heart  is  much  dilated. 

I  have  seen  a  case  lately  in  which  removal  of 
three-quarters  of  the  thyroid  had  little  or  no 
effect  on  the  symptoms,  and  in  which  para- 
thyroid and  intestinal  antiseptics  have  nearly 
cured  all  the  symptoms. 

My  contention  is  that  we  have  in  this  disease 
a  pluriglandular  disturbance,  not  only  as  to 


148    ESSAYS  ON  PRACTICAL   MEDICINE 

quantity  of  secretion,  but  as  to  quality  also, 
and  that  this  disturbance  is  in  the  great 
majority  of  cases  caused  by  bacterial  poisons 
from  within.  Shock,  grief  and  fright  are,  I 
think,  only  emergencies  stirring  up  partly  latent 
trouble.  These  glandular  disturbances  act 
partly  by  direct  action  on  certain  organs,  such  as 
the  heart  and  sympathetic  ganglia,  but  chiefly, 
perhaps,  by  producing  discord  in  the  glandular 
system  of  the  whole  body.  The  newer  phy- 
siology has  given  us  a  glimpse  of  the  wonderful 
perfection  and  delicacy  of  that  vital  machinery  ; 
surely,  then,  it  should  point  the  way  to  a  return 
from  these  jangling  discords  to  the  oldharmonies 
of  health.  The  first  two  cases  I  have  quoted 
were  brought  under  treatment  in  the  early 
stages ;  mostly,  we  have  not  the  chance  of 
seeing  them  till  the  symptoms  have  been  going 
on  for  some  time,  and  when  secondary  damage 
has  been  done.  We  have  then  to  call  other 
glands  to  our  aid.  Thyroid,  we  know,  in  the 
active  onset  of  the  disease,  does  harm  and 
increases  the  tachycardia. 

For  many  years,  the  action  of  suprarenal  in 
this  disease  has  been  advocated.  Some  phy- 
sicians, hke  the  late  Sir  Lauder  Brunton,  have 
succeeded  with  it,  while  others  have  failed. 


SPECULATIONS   AND   DOUBTS         149 

I  think  the  error  has  arisen  in  the  choice  of 
cases,  though  in  most  it  is  of  some  help. 

Schafer  says  on  this  point,  referring  to  the 
sympathetic  excitability  seen  in  this  disease : 
"  Here  the  question  arises,  Is  this  a  direct 
effect  on  the  sympathetic  system  ?  Or  is  it 
indirect  through  the  adrenals,  which  are  stimu- 
lated to  increased  activity  by  the  excess  of 
thj^ine  in  the  blood  ?  The  answer  is  not  easy  ; 
but  it  may  be  stated  that  although  certain 
symptoms  of  hyperthyroidism  are  similar  to 
those  produced  by  excess  of  adrenine  in  the 
blood,  others  are  not  so — ^this  is  the  case  with 
flushing  of  the  skin,  which  is  due  to  vascular 
dilatation,  whereas  adrenine  ordinarily  produces 
vaso-contraction  ;  moreover,  it  is  undoubtedly 
the  case  that  the  administration  of  adrenine 
exercises  a  markedly  beneficial  effect  in  some 
cases  of  the  disease — a  fact  which  would  be 
inexplicable  on  the  theory  that  the  results  of 
hyperthyroidism  are  simply  due  to  excitation 
of  the  suprarenals  and  to  the  production  of  an 
excess  of  adrenine." 

Systematic  observation  of  the  blood-pressure 
shows  daily  and  hourly  variations ;  mostly 
it  is  sKghtly  raised,  but  it  is  often  much  below 
the  normal  (Dr.  Norman's  case). 


I50     ESSAYS   ON   PRACTICAL   MEDICINE 

The  sphygmomanometer  should  be  our  guide 
to  the  use  and  dosage  of  suprarenal  extract ; 
the  flushed,  hypersemic,  perspiring  skin  would 
point  also  to  its  beneficial  use,  and  any  exces- 
sive rise  of  blood-pressure  can  be  met  by 
hippurates  or  nitrites. 

In  nearly  all  cases  we  have  in  the  circulation 
a  plus  condition  of  thyrine  and  probably  a 
perverted  condition  as  well ;  we  have  also  a 
plus  condition  of  adrenine.  May  not  this  be 
an  effort  of  nature  not  only  to  balance  the 
depressor  effect  of  thyrine,  but  to  correct  its 
quality  also  ?  The  cases  which  show  an 
habitual  low  blood-pressure  are,  in  my  opinion, 
more  severe  and  more  Hkely  to  develop  the 
later  serious  cardiac  symptoms.  It  may  be 
these  cases  that  benefit  so  much  from  suprarenal 
treatment.  The  combination  in  these  cases  of 
suprarenal  and  parathyroid  treatment  is  very 
effectual. 

In  acute  febrile  diseases,  as  pneumonia  and 
diphtheria,  when  the  blood-pressure  falls  very 
low,  suprarenal  will  soon  raise  the  pressure  to 
the  patient's  great  advantage.  Pituitrin  and 
thymus  have  been  used,  but  there  is  no  great 
weight  of  testimony  in  their  favour. 

The  critic  will  say,  perhaps,  "  Is  not  this 


SPECULATIONS   AND   DOUBTS         151 

therapeusis  as  speculative  as  its  physiology  ? 
If  it  is,  where  is  the  danger  ?  "  We  are  not 
dealing  with  dangerous,  exogenous  poisons. 
How  many  of  our  successful  remedies  have 
come  from  pure  empiricism  ?  Here  we  are, 
doubtless,  empirics,  but  working  on  and  from 
physiological  data.  The  investigation  and 
discoveries  of  endocrinology  point  in  Graves' 
disease  to  a  pluriglandular  disturbance,  and  it 
must  be  met  and  conquered  by  pluriglandular 
aids. 

Biedl,  after  all  his  years  of  patient,  brilliant 
work,  sums  up  the  subject  in  this  impotent 
manner  : 

*'  The  results  of  organotherapy  in  Graves' 
disease  are  interesting  only  in  so  far  as  they 
furnish  direct  evidence  against  the  assumption 
of  a  hypothyroidism  in  this  condition.  The 
effect  produced  by  thyroid  extract  is  universally 
the  exaggeration  of  the  disease.  Attempts  to 
treat  Graves'  disease  with  extracts  of  thymus 
ovary  and  suprarenal  have  a  certain  theoretic 
interest,  but  are  of  no  practical  significance." 

This  is  a  typical  example  of  the  limitations 
of  the  scientific  mind.  He  brings  one  within 
sight  of  the  promised  land,  and  then  throws 
doubts  on  its  very  existence. 


152     ESSAYS   ON   PRACTICAL   MEDICINE 

It  is  only  exceptional  minds,  like  Lord 
Kelvin's  and  Lauder  Brunton's,  that  can  trans- 
late their  deep  knowledge  into  beneficial  action. 
On  the  other  side,  Rudinger  says  (to  go  back 
to  parathyroid) : 

"  We  have  to  suppose  that,  under  normal 
conditions,  the  function  of  the  one  gland  (thy- 
roid and  parathyroid)  is  controlled  by  the  other, 
and  that  when  the  balance  is  disturbed  by 
the  extirpation  of  one,  the  remaining  organ 
becomes  functionally  and  later  organically 
hyper  trophied/' 

He  brings  the  following  as  evidence  in 
support  : 

"  Moussa  and  Channin  found  that  the  ex- 
hibition of  the  parathyroid  gland  of  horses 
was  followed  by  unfavourable  symptoms  in 
myxoedema,  but  that  in  Graves'  disease  it 
had  a  very  beneficial  effect.  Rudinger  believes 
that  the  hyperf unction  of  the  thyroid  in  Graves' 
disease  is  restored  by  the  exhibition  of  para- 
thyroid, while  in  myxoedema  the  hypofunction 
is  intensified.  He  also  is  inclined  to  attribute 
the  favourable  action  of  Moebius'  serum  and 
of  rhodagen  to  the  presence  of  a  large  propor- 
tion of  parathyroid  secretion.  The  removal  of 
the  thyroid  permits  of  an  increased  activity  on 


SPECULATIONS   AND   DOUBTS         153 

the  part  of  the  parathyroids  ;  thus,  the  serum 
and  the  milk  contain  substances  which,  being 
stronger  than  those  in  normal  serum  and  milk, 
are  better  able  to  counteract  the  activity  of  the 
thyroid  gland.  Rudinger,  as  the  result  of  his 
investigations  with  Eppinger  and  Falta  on  the 
action  of  adrenaUn  in  thjnroidectomised  animals 
(with  regard  to  the  ensuing  glycosuria),  infers 
that  thyroid  secretion  stimulates  the  sympa- 
thetic nerve,  while  that  of  the  parathjo-oids 
has  an  inhibitory  effect  on  it.  Stimulation  and 
inhibition  are  so  balanced  by  the  activity  of 
the  two  glands  that,  under  normal  conditions, 
oscillation  is  possible  within  a  very  small  range 
only. 

"The  suppression  of  the  thyroid  secretion 
reduces  the  irritability  of  the  sympathetic 
nerve,  not  only  by  robbing  it  of  its  stimulating 
agent,  but  by  releasing  the  inhibitory  effects 
of  the  parathyroid.  With  the  extirpation 
of  the  parath5n:oids  the  inhibitory  agent  is 
removed,  and  this  brings  in  its  train  a 
condition  of  hypersensibility  of  the  sympa- 
thetic.'^ 

In  paralysis  agitans  and  tetany,  which  bear 
many  points  of  relation  to  Graves'  disease, there 
is  almost  certainly  parathyroid  deficiency  ;   at 


154     ESSAYS   ON   PRACTICAL   MEDICINE 

any  rate,  they  are  much  benefited  by  para- 
thyroid feeding. 

Schafer,  on  this  point,  says:  **  The  most 
satisfactory  explanation  of  the  nervous  results 
of  the  removal  of  the  parathyroids  is  the 
assumption  that  they  yield  to  the  blood  a 
special  autacoid— presumably  of  a  chalonic  or 
restraining  nature — ^which  tends  to  prevent 
over-excitation  of  nerve  cells.  This  hypo- 
thetical autacoid — ^which  has  not  yet  been 
isolated — ^may  provisionally  be  termed  para- 
thyrine.  We  shall  see  that  there  is  reason  to 
beHeve  that  the  thyroid  produces  an  autacoid 
with  an  opposite  tendency/' 

Halpenny  and  Thompson,  as  a  result  of 
observations  on  dogs  after  parathyroidectomy, 
see  good  reason  to  believe  that  the  parathyroid 
exercises  an  inhibitory  influence  upon  the 
thyroid  itself,  as  well  as  on  the  sympathetic 
system. 

In  the  clinical  study  of  all  diseases  of  the 
thyroid  apparatus,  we  see  compHcations  arising 
that  are  more  or  less  absent  in  the  laboratory. 
It  is  rare,  I  think,  to  get  disease  of  the  thyroid 
or  parathyroids  pure  and  simple  ;  that  is  to 
say,  without  the  involvement  of  the  other  to 
some  extent.     This  makes  the  treatment  of 


SPECULATIONS   AND   DOUBTS         155 

either  Graves'  disease  or  myxoedema  a  more 
subtle  but  more  interesting  study. 

When  one  reads  Kocher's  well-known  list 
of  symptoms  of  the  two  diseases  in  parallel 
columns,  one's  first  thought  is,  that  never  were 
two  diseases  with  such  complete  contrasts,  but 
his  description  of  the  symptoms  is  at  the 
acme  of  their  activity,  and  the  later  study  of 
individual  cases  will  often  show  a  slow  merging 
of  one  into  the  other  or  at  any  rate  of  Graves' 
into  myxoedema.  Hyper  function,  if  long-con- 
tinued, must  lead  to  hypertrophy  and  ulti- 
mately to  atrophy.  We  see  this  hypofunction 
ending  in  a  form  of  myxoedema  at  the  end  of 
a  fair  number  of  Graves'  diseases.  This  fact 
should  make  us  pause  and  very  carefully  con- 
sider before  we  sanction  the  operation  of 
thyroidectomy.  The  complete  removal  of  the 
gland  is,  as  we  know,  disastrous,  and  in  the 
partial  removal,  which  has  often  shown  at  first 
brilliant  results,  we  know  little  of  the  after- 
history. 

How  do  such  cases  fare  in  real  old  age,  when 
we  want  all  the  thyroid  we  can  get,  and  most 
of  us  a  bit  more  ? 

With  a  noisy,  turbulent  crowd  in  a  music- 
hall,   the  chucker-out  is  a  necessary  bit  of 


156     ESSAYS   ON   PRACTICAL   MEDICINE 

brutality ;  but  all  our  endocrine  glands,  even 
when  quarrelsome,  are  essential  to  our  well- 
being,  and  so  the  chucker-out,  in  the  form 
of  the  surgeon,  should  be  the  last  court  of 
appeal. 

There  are  some  cases  that  have  become  so 
severe  that  his  help  is  necessary,  but  his 
appearance  on  the  stage  is  a  great  reflection  on 
our  therapeutic  weapons  and  skill. 

Wendell  Holmes  has  somewhat  sarcastically 
called  the  profession  of  undertaker  the  post- 
medical  profession.  In  Graves'  disease,  we 
should  not  allow  the  surgeon  to  earn  and 
assume  this  honourable  title.  That  brilliant 
craftsman,  the  thyroidectomist,  should  become 
an  anachronism,  a  tradition  only  of  the  dark 
days  that  are  gone  ;  and  medicine,  strong 
in  physiological  faith,  should  resume  her 
peaceful  sway.  Midway  between  medicine 
and  surgery  comes  the  X-ray  treatment.  This 
method  has  been  so  improved  of  late  by  the 
combination  of  the  sinusoidal  current  with 
X-rays  that  experts  feel  confident  that  they 
can  avoid  permanent  injury  to  the  gland  (see 
Dr.  Hernaman  Johnson's  wise  and  temperate 
letter  in  the  Lancet  of  December  29,  1917),  but 
one  cannot  help  feeling  that,  in  any  but  the 


SPECULATIONS  AND   DOUBTS         157 


most  skilled  hands,  there  must  be  some  risk  of 
injury  which  may  only  show  itself  in  the  far 
future. 

The  treatment  by  the  judicious  combina- 
tion of  X-rays  with  the  internal  glands  holds 
out,  I  feel  sure,  a  most  hopeful  prospect.  In 
medicine,  then,  we  must  be  boldly  radical,  but 
in  surgery  wisely  conservative,  for 

"  The  mill  will  never  grind  again 
With  the  water  that  has  passed." 

Since  writing  the  above,  Dr.  Hertz  of  Guy's 
has  published  a  most  interesting  case  of  para- 
thyroid insufficiency  in  "  Endocrinology,''  1918. 
This,  I  think,  corroborates  fully  my  views  on 
connection  between  Graves'  disease  and  para- 
thyroid insufficiency,  and  also  explains  the 
success  of  parathyroid  feeding. 

In  the  suprarenal  gland  we  have  another 
most  interesting  field  of  study.  As  we  all 
know,  this  gland  is  composed  of  two  portions, 
the  cortex  and  the  medulla.  Physiologists  are 
still  in  doubt  as  to  the  properties  of  the  former, 
though  their  speculations  are  full  of  interest. 
In  the  medulla,  from  which  we  get  our  supra- 
renal extract,  the  cells  peculiar  to  it  are 
derived  from  the  same  tissue,  morphologically, 


158     ESSAYS  ON  PRACTICAL   MEDICINE 

as    the    ganglion    cells   of    the    sympathetic. 
Elliott  graphically  says  :    *'  The  adrenine  cells 
and    the    ganglion    cells    are    closely   related 
stations  on  the  great  sympathetic  highway  that 
reaches  from  the  central  nervous  system  to  the 
blood-vessels.     The  adrenine  cell  is  essentially 
a  part  of  the  nervous  system,  and  in  reality  not 
a  peripheral  cell  at  all."    But  apart  from  its 
nerve    connection    and   influence    this   gland 
has  a  chemical  action  which  seems  to  be  inde- 
pendent of  its  nerve  action  ;   this  exists  in  its 
chromaffin  tissue,  which  Noel  Paton  describes 
thus  :  *'  The  chromaffin  tissue  may  be  defined  as 
a  tissue  composed  of  cells  derived  from  the  nerve 
cells   of   the   abdomino-thoracic   sympathetic 
system,  which  stain  a  brown  colour  with  chrome 
salts   and   which    produce    a    physiologically 
active  substance  called  adrenine."    This  sub- 
stance can  be  produced  synthetically.    When 
injected  into  the  blood-vessels  it  stimulates  the 
terminations  of  the  true  sympathetic  in  visceral 
muscle  and  in  glands,  and  it  acts  on  these  ter- 
minations alone.     That  adrenine  has  a  double 
way  of  action  is  proved  by  the  fact  that  all  the 
nerves  of  the  sympathetic  group  may  be  re- 
moved and  yet  the  animal  will  live  ;    but  if 
the  glands  themselves  are  removed  the  animal 


SPECULATIONS  AND   DOUBTS         159 

inevitably  dies,  showing  that  the  passage  of 
adrenine  into  the  blood  stream  is  necessary  to 
life.  It  is  important,  in  investigating  the  range 
of  action  of  this  internal  secretion,  to  remember 
this.  Elliott  says  again  :  *'  Adrenine  has  the 
remarkable  power  of  stimulating  only  that 
plain  muscle  in  the  body  which  is  supplied 
by  the  sympathetic  nerves,  and  the  action 
produced  by  it  is  always  identical  with  that 
caused  by  electrical  stimulation  of  the  nerves. 
The  chemical  substance  circulating  in  the  blood 
evokes  exactly  the  same  response  as  does  the 
nervous  impulse — each  reinforces  the  other." 
To  use  a  homely  simile,  this  front-  and  back- 
stairs passage  for  its  influence  shows  its  great 
importance  in  the  animal  economy. 

The  suprarenal  glands  are  very  richly  sup- 
plied with  nerves  from  the  splanchnic  direct, 
and  from  the  suprarenal  plexus.  It  is  probably 
with  one  exception  the  most  vascular  organ 
in  the  body.  The  following  is  a  short  extract 
from  Schafer's  lecture  :  *'  If  an  extract  of 
suprarenal  capsule  be  injected  into  the  vein  of 
an  animal,  the  first  effect  is  an  immediate  and 
marked  rise  of  blood-pressure  ;  this  can  be 
shown  to  be  caused  by  contraction  of  the 
peripheral  arteries.     Along  with  this  contrac- 


i6o     ESSAYS   ON  PRACTICAL   MEDICINE 

tion  a  slowing  of  the  heart's  action  may  occur, 
due  to  an  effect  on  the  cardio-inhibitory  centre, 
and  this  may  hmit  somewhat  the  rise  of  blood- 
pressure.  But  if  the  vagi  are  cut  or  paralysed 
by  atropine,  the  heart's  action  becomes  very 
accelerated,  and  also  augmented  in  force  (pri- 
marily by  the  action  of  the  autacoid  on  the 
auricles  but  also  somewhat  on  the  ventricles), 
and  this  greatly  increases  the  rise  of  blood- 
pressure.  The  effect  on  the  vessels  lasts  a  few 
minutes,  passing  off  gradually ;  afterwards 
the  blood-pressure  is  usually  a  little  lower  than 
before.  The  arteries  which  are  most  affected 
are  those  of  the  splanchnic  area  ;  those  of 
the  limbs  and  trunk  rather  less,  although  the 
cutaneous  vessels  are  often  strongly  contracted  ; 
those  of  the  pulmonary  system  and  of  the 
brain  only  very  sHghtly,  if  at  all,  and  those 
of  the  coronary  circulation  not  at  all.  It  is 
always  the  smaller  vessels  that  are  most 
affected,  and  in  consequence  of  the  great  rise 
of  pressure  which  their  contraction  produces, 
the  larger  arteries  tend  to  become  passively 
dilated  ;  this  dilatation  may  be  very  great. 
The  effect  upon  the  vessels  is  seen  after  com- 
plete destruction  of  the  central  nervous  system, 
and  after  severance  of  nerves  to  the  part.     It 


SPECULATIONS   AND   DOUBTS         i6f 

is,  therefore,  due  to  a  direct  action  of  the 
autacoid  principle  of  the  gland  on  the  con- 
tractile tissue  of  the  heart  and  vessels  ;  never- 
theless such  action  only  occurs  in  tissues  which 
are  supplied  by  the  sympathetic  system,  and 
severance  of  the  nerves,  so  far  from  stopping 
the  action,  tends  to  make  the  tissues  supplied 
by  the  severed  nerve  more  easily  excited  by 
the  autacoid.  Gunn  and  Chavasse  have  shown 
that  adrenine  has  also  an  action  upon  the 
muscular  coat  of  veins,  causing  tonic  contrac- 
tion in  peripheral  veins  and  rhythmic  con- 
traction of  the  superior  vena  cava  near  the 
heart." 

To  arrive  at  the  wonderful  and  beneficial 
results  that  may  be  obtained  clinically  from 
this  powerful  extract,  one  must  think  very 
deeply  over  all  these  physiological  experiments 
and  results.  We  have  evidently  a  weapon  that 
may  be  powerful  for  good  or  for  evil,  and 
one  that  must  be  used  in  accordance  with  our 
reasoning  powers  and  our  knowledge.  Elliott 
says  in  his  eloquent  way :  "  The  adrenal 
glands,  whether  medulla  alone  or  cortex  and 
medulla,  are  concerned  in  maintaining  the 
steady  tone  of  all  muscles  innervated  by  the 
sympathetic  nerves.  They  are  responsible  day 
II 


i62     ESSAYS  ON  PRACTICAL   MEDICINE 

by  day  for  the  upholding  touch  that  maintains 
the  driving  power  of  the  pulsating  current  of 
blood  by  which  we  live.  The  nervous  im- 
pulses, which  play  upon  these  muscles,  merely 
serve  to  change  the  tension  up  and  down,  here 
and  there,  where  special  circumstances  require 
more  delicate  adjustment  to  local  and  peculiar 
needs  of  the  body." 

We  have,  then,  before  us  the  power  which 
by  way  of  the  blood  and  by  way  of  the  sym- 
pathetic activates  and  controls  the  energy  of 
the  heart  muscle  and  the  force  of  its  contrac- 
tions, and  which  also  controls  that  most  im- 
portant property,  the  tonicity  of  the  muscles 
of  the  heart  and  of  the  arteries.  When  we 
learn  how  to  use  this  power  wisely  and  in  ac- 
cordance with  physiological  laws,  we  shall  have 
probably  the  most  effective  heart  tonic  in  our 
repertoire.  To  compare  it  accurately  with 
digitalis  takes  a  better  pen  and  mind  than 
mine,  but  one  may  briefly  say,  I  think,  that 
digitalis  acts  firstly  as  a  tonic  on  the  vagus 
roots,  and  so  on  the  inhibition  of  the  heart, 
and  that  adrenalin  acts  chiefly  and  firstly  on 
the  sympathetic  system  and  so  on  the  stimula- 
tion of  the  heart ;  the  one  on  the  vegetative 
nervous  system,  the  other  on  the  autonomous. 


SPECULATIONS  AND  DOUBTS        163 

Both  remedies,  if  pushed  too  far,  extend  their 
action  to  the  other  division  of  the  nervous 
system,  and  in  poisonous  doses  produce  results 
quite  opposite  to  their  primary  ones.  If  we 
have  an  open  choice  of  remedies,  I  think  we 
should  choose  the  ones  that  already  belong  to 
the  animal  system.  Just  now  we  are  perhaps 
unduly  prejudiced  against  aliens.  They  have 
been  yery  useful  in  the  past,  but  I  think  the 
time  has  now  come  for  the  use  and  protection 
of  native  goods  and  industries.  One  cannot 
help  feeling  that  the  foreigner  has  something 
harmful  up  his  sleeve.  In  ordinary  practice 
intravenous  injections  are  not  possible,  so  we 
must  consider  only  the  hypodermic  and  the 
oral  method  of  administration.  Some  authori- 
ties say  that  adrenalin  given  hypodermically 
takes  a  long  time  to  get  into  the  circulation, 
but  if  one  has  watched  the  rapid  relief 
that  it  gives  to  spasmodic  asthma  one  can 
hardly  accept  this  statement.  No  doubt  the 
local  astringent  action  delays  its  absorption 
somewhat,  but  I  think  this  may  be  got  over  by 
combining  with  it  2  minims  of  liq.  trinitrin, 
and  by  further  dilution.  One  may  make  an 
interesting  speculative  study  of  the  effects  of 
adrenalin  and  of  chloroform  narcosis  on  the 


164     ESSAYS  ON  PRACTICAL   MEDICINE 

heart.  If  adrenalin  be  given  in  too  concen- 
trated a  form  there  is  often  a  period  of  half  a 
minute  or  more  when  the  heart's  action,  in- 
stead of  being  strengthened,  wobbles  and  has 
a  halting  gait,  and  the  patient  becomes  pale 
and  faint ;  in  the  same  way  there  is  often  such 
a  period  of  uncertainty  at  the  commencement 
of  chloroform  narcosis.  Can  these  effects  be 
accounted  for  thus  ?  Under  chloroform  the 
chief  control  of  the  heart,  in  French  I'ordre 
superieur,  passes  from  the  vagus,  the  servant 
of  the  vegetative  nervous  system,  and  is  taken 
up  by  the  sympathetic,  the  servant  of  the 
autonomous  system.  The  same  happens,  I 
think,  when  we  give  a  full  dose  of  adrenahn. 
It  is  in  this  transition  period,  when  the  gears 
are  being  changed,  that  danger  is  present. 
This  has  been  overcome  to  some  extent  of  late 
years,  in  anaesthetic  work,  by  giving  an  injec- 
tion of  morphia  and  scopolamine  or  of  morphia 
and  atropine  shortly  before  the  chloroform. 
The  effect  of  this  is  partly  to  paralyse  the 
vagus  and  so  to  put  it  out  of  action.  This 
makes  the  change  of  gears  more  rapid  and 
easy.  In  the  same  way,  I  believe,  the  addi- 
tion of  atropine  or  scopolamine  to  adrenalin 
would  produce  a  safer  and  more  rapid  effect. 


SPECULATIONS   AND   DOUBTS         165 


My  physiology  may  be  wrong,  but  I  think 
my  facts  are  right. 

To  return  to  the  practical  point  of  adrenalin 
dilution.  This  case  illustrates  my  point.  A 
clever,  observant  woman,  who  has  spasmodic 
asthma  very  severely,  finds  her  only  relief  from 
hypodermic  injections  of  adrenahn.  She  was 
at  first  told  to  use  eight  to  ten  minims  neat ; 
each  time  she  felt  very  faint,  and  became  so 
pale  that  her  relations  begged  her  to  give  it 
up.  By  diluting  eight  minims  with  twelve  of 
sterilised  water  these  bad  effects  never  occurred 
and  the  good  effects  were  continued. 

To  show  the  far-reaching  effects  of  the  supra- 
renal secretion,  and  as  an  incentive  to  the 
deeper  study  of  its  possibilities,  I  give  Dr. 
George  Murray's  words  from  his  article  in  the 
Practitioner  of  February  1915  :  "It  has  been 
shown  clearly  by  the  investigations  of  Elliott, 
Cannon,  and  others  that  under  the  influence  of 
a  strong  stimulus,  such  as  fright,  adrenine  is 
rapidly  discharged  into  the  adrenal  veins  and 
so  into  the  general  circulation.  It  is  interesting 
to  follow  up  the  effects  of  this  condition  of 
adrenalsemia  and  to  see  how  useful  they  may 
be  to  an  animal  either  in  contending  with  or 
escaping  from  the  cause  of  fear.    The  excess 


i66     ESSAYS   ON   PRACTICAL   MEDICINE 

of  adrenine  dilates  the  coronary  arteries, 
giving  the  heart  a  larger  supply  of  blood,  in- 
creases the  strength  of  the  cardiac  contractions, 
and  raises  the  blood-pressure.  It  tends  to 
divert  the  chief  flow  of  blood  from  the  ab- 
dominal vessels  to  those  of  the  central  nervous 
system,  heart,  lungs,  and  muscles.  The  adre- 
nine thus  stimulates  just  those  activities  which 
an  animal  employs  either  in  fighting  a  foe  or 
in  escaping  from  an  enemy.  In  addition  to 
this,  the  adrenine  mobihses  the  store  of  glyco- 
gen in  the  Hver,  thus  increasing  the  amount 
of  sugar  in  the  blood  and  rendering  it  avail- 
able for  use  in  the  muscular  action  entailed 
by  the  effort.*' 

Transferring  the  consideration  of  these  facts 
to  our  own  more  placid  lives,  may  we  not 
discover  many  analogies  and  aids  to  help  us 
in  the  fight  against  disease,  and  methods  of 
escape  also  from  the  attacks  of  our  microbic 
and  other  enemies  ?  This  force  is  ever  quietly 
working  to  maintain  and  protect  us  ;  it  must 
be  our  aim  to  support  this  friendly  power, 
and  to  supplement  it  if  need  arise.  We 
see  in  Addison's  disease  how  the  destruction 
of  this  organ  and  the  consequent  absence  of 
its  secretion  soon  ends  in  progressive  debihty 


SPECULATIONS   AND   DOUBTS         167 

and  death,  but  also  we  see  that  from  the  same 
cause  our  defences  are  broken  down  and  the 
body  hes  open  to  any  attack.  In  not  a  few 
other  acute  diseases,  such  as  diphtheria  and 
cholera,  the  suprarenal  secretion  is  partly  or 
entirely  suppressed,  and  this  is  probably  one 
of  the  chief  causes  of  the  muscular  and  cardiac 
weakness,  and  of  the  loss  of  arterial  tone  that 
so  often  seems  to  be  the  cause  of  death.  In  all 
these  diseases  suprarenal  extract  or  adrenalin 
injections  have  already  proved  very  useful. 
In  pneumonia  especially,  a  falling  blood-pres- 
sure should  be  the  sign  for  the  use  of  this 
remedy,  and  it  should  be  given  freely  and  con- 
tinuously. In  addition  to  its  good  effect  on 
contractility  and  tonicity,  it  is  in  many  cases 
a  good  timer  of  the  heart.  I  have  seen  cases 
of  auricular  fibrillation  yield  to  it  when  digi- 
talis has  failed.  Its  rather  unexpected  action 
on  spasmodic  asthma  is  not  easy  to  explain, 
but  it  is  probably  due  chiefly  to  its  stimulating 
effect  on  the  sympathetic  nerve  endings  and 
'  by  this  effect  overcoming  the  muscular  spasm, 
arising  from  over-action  of  the  vagus.  Its 
power  of  dilating  the  coronary  arteries  may 
also  be  a  factor.  The  local  action  of  adrenalin 
is  so  well  known  that  I  need  not  tpuci  on  it,. 


i68    ESSAYS   ON  PRACTICAL   MEDICINE 

There  remains  the  question  of  the  mode  of 
internal  administration.  To  give  the  Hquor 
adrenalin  would  at  first  sight  seem  to  be  the 
easier  and  the  more  scientific  way,  but  as  a 
matter  of  experience  it  is  found  that  it  has  in 
most  cases  but  little  general  effect  when  given 
by  the  stomach.  Grunbaum  says  that  even 
in  doses  of  60  minims  it  fails  to  raise  the  blood- 
pressure.  The  explanation  probably  is  that  it 
has  such  an  astringent  or  blanching  effect  on 
the  gastric  mucous  membrane  that  absorp- 
tion is  very  slow.  This  local  effect  is  very 
valuable  in  cases  of  hsematemesis.  At  present 
we  can  best  get  the  effects  we  aim  at  by  giving 
extract  of  the  gland,  and  this  is  best  given 
in  the  tablet  form — 5-grain  tablets  may  be 
given  every  two  hours  in  emergencies.  The 
manometer  will  always  show  when  enough  has 
been  given.  Some  writers  say  that  this 
method  is  ineffectual,  but  that  is  quite  con- 
trary to  my  experience,  and  we  must  remem- 
ber that  Oliver  and  Schafer's  original  experi- 
ments, which  have  so  largely  led  to  our  present 
knowledge,  were  made,  as  Dr.  Oliver  has  him- 
self told  me,  with  teaspoonful  doses  of  a  strong 
glycerine  extract  or  emulsion  of  the  supra- 
jenals  of  the  sheep ;   it  therefore  seems  prob- 


SPECULATIONS   AND   DOUBTS         169 

able  that  large  doses  are  required  to  produce 
their  physiological  results,  and  here,  as  so  often 
happens,  want  of  courage  leads  to  want  of 
faith.  The  ideal  method,  of  course,  in  emer- 
gencies especially,  is  by  intravenous  injection, 
but,  except  in  hospital  practice,  that  is  rarely 
possible. 

One  more  gland  remains  for  special  notice — 
the  pituitary.  In  recent  years  the  powers 
of  this  gland  have  been  recognised  as  very 
remarkable,  and  apparently  neither  life  nor 
health  can  exist  for  any  length  of  time  when 
it  is  destroyed.  The  anatomy,  position  and 
histology  it  is  needless  for  me  to  describe,  but  a 
careful  study  of  its  structure  will  help  towards 
a  grasp  of  its  physiological  properties  and 
possibilities.  To  make  a  brief  summary,  ap- 
parently as  far  as  our  present  knowledge  goes, 
the  anterior  or  glandular  portion  is  the  part 
essential  to  life.  It  is  this  portion  also  which 
governs  the  growth  of  the  body,  and  particularly 
of  the  skeleton.  The  abnormal  conditions  of 
gigantism,  infantilism  and  acromegaly  belong, 
it  is  thought,  to  faulty  conditions  of  this  part. 
The  pars  intermedia  secretes  one  or  more 
hormones  that  affect  the  heart  and  circulation 
in  the  manner  describecj  below.     They  also 


I70     ESSAYS   ON   PRACTICAL   MEDICINE- 

increase  the  activity  of  smooth  muscle  and 
cause  an  increase  of  gastric,  renal  and  mam- 
mary secretion.  The  active  principles  that 
affect  the  circulation  are  found  more  in  the  pars 
posterior,  but  it  is  beheved  that  they  are  only 
passing  through,  from  the  intermedia,  where 
they  arise,  to  the  third  ventricle,  and  subse- 
quently by  that  route  into  the  cerebro-spinal 
fluid.  Experimentally  the  effect  of  these  ex- 
tracts upon  the  heart  and  blood-vessels  is  a 
direct  one,  and  is  not  due,  as  in  the  suprarenal 
autacoid,  to  its  stimulant  action  on  the  sym- 
pathetic nerve  endings.  The  effect  on  the 
heart  is  also  different ;  for  whereas — ^with 
the  vagi  cut  or  paralysed — adrenine  causes  a 
marked  acceleration  of  the  heart  (sympathetic 
stimulation),  the  pituitary  causes  a  slowing 
of  the  heart's  action  along  with  increased 
force.  Moreover,  while  adrenine  produces 
dilatation  of  the  coronary  vessels  the  auta- 
coid of  the  pituitary  constricts  them,  as  it 
does  other  systemic  arterioles,  and  the  same  is 
the  case  with  the  pulmonary  vessels. 

The  interrelationship  of  this  gland  with  the 
other  internal  secretory  glands  is  very  intimate 
and  important,  and  is  well  worth  study.  The 
practical  applications  of  pituitary  extract  that 


SPECULATIONS   AND   DOUBTS         171 

interest  us  are  firstly  its  effect  on  the  heart  and 
circulation,  as  described  above,  in  which  it  has 
proved  to  be  a  very  valuable  ally  to  adrenine 
and  to  the  digitalis  group.  Secondly,  its 
action  on  the  uterus.  Here  in  obstetric  prac- 
tice it  is  most  effectual.  Schafer  says  :  "  The 
uterus  under  its  influence  is  rendered  more 
excitable  to  influences  reaching  it  through  its 
nerves.  Pituitary  extract  probably  acts  on 
plain  muscle  more  by  increasing  its  sensitive- 
ness to  normal  stimuli,  than  by  acting  as  a 
direct  excitant.  Thus,  when  given  in  preg- 
nancy before  the  commencement  of  parturition 
it  produced  no  effect,  but  its  action  during 
parturition  is  well  marked."  In  cases  of 
uterine  inertia  before  and  after  birth  it  is 
probably  the  most  rapid  and  powerful  remedy 
that  we  have.  Thirdly,  in  intestinal  inertia 
and  meteorism,  that  so  often  occur  after 
abdominal  operations,  this  remedy  will  often 
restore  the  muscular  tone,  and  will  help  much 
towards  the  expulsion  of  the  bowel  contents. 
Fourthly,  its  very  valuable  action  on  the 
kidneys  as  a  diuretic  ;  this  has  not  been  as  yet 
fully  worked  out  from  the  clinical  side,  but 
probably  it  will  be  of  most  use  in  the  renal 
inadequacy  of  heart  disease  and  in  most  forms 


172     ESSAYS   ON   PRACTICAL   MEDICINE 

of  dropsy.  Fifthly,  it  is  a  very  powerful 
restorative  in  all  forms  of  shock.  Its  good 
action  on  arterial  tension  is  not  repeated  by  a 
second  dose,  at  any  rate  if  given  within  a  few 
hours  ;  but  on  the  heart  muscle,  the  uterus, 
the  intestine  and  the  kidney  it  can  be  given 
frequently  with  good  effect.  Some  writers 
claim  that  it  has  a  good  effect  in  Graves'  disease, 
and  its  similarity  in  some  respects  to  adrenine 
would  certainly  suggest  its  use.  The  oral  use 
of  pituitary  extract  has  so  far  proved  to  be  un- 
satisfactory. The  active  principle  of  the  pars 
posterior  seems  to  be  destroyed  by  the  gastric 
juice  and  to  be  inert. 

The  action  of  pitglandin  (the  American  name 
for  the  extract  of  the  pars  anterior  of  the 
pituitary)  has  only  come  into  scientific  notice 
the  last  two  years.  Its  influence  on  growth 
and  development  is  known  to  be  so  important 
that  one  is  convinced  that  there  must  be  some 
valuable  therapeutic  use  for  it.  About  two 
years  ago.  Dr.  Robertson  and  his  colleagues  in 
the  CaHf ornia  University  succeeded  in  isolating 
from  the  pars  anterior  a  chemical  substance, 
which  they  named  tetheHn  ;  this  when  available 
may  help  us  to  get  better  and  more  reliable 
results  than  the  dry  glajid  e^ctjract  itself  gives. 


SPECULATIONS   AND  DOUBTS         173 

The  powerful  and  almost  poisonous  effects  of 
the  whole  gland,  which  included  of  course  the 
pars  posterior,  have  hitherto  prevented  con- 
clusive trials,  but  it  is  now  found  that  the 
anterior  lobe  extract  can  be  used  in  very 
large  doses,  and  that  small  doses  produce  but 
little  effect ;  indeed,  we  may  almost  say  that 
there  is  nothing  toxic  in  pitglandin.  The 
well-known  connection  between  the  pars 
anterior  and  the  process  of  growth  points  to 
its  use  in  delayed  or  defective  development, 
and  the  results  are  already  more  than  encourag- 
ing, but  the  most  striking  results  are  perhaps 
on  the  nervous  system.  Dr.  Harrower,  the 
first  editor  of  "  Endocrinology,"  says,  "  This  re- 
medy has  undoubted  virtue  in  Graves'  disease." 
Richter  (Medical  Herald,  Kansas  City)  says: 
**  Four  cases  of  ambulatory  Graves'  disease  have 
been  materially  benefited  by  the  administra- 
tion for  several  weeks  of  pitglandin.  All  cases 
showed  well-marked  symptoms,  and  all,  because 
of  their  circumstances,  were  forced  to  forgo 
the  advantages  of  rest  and  suitable  hygienic 
treatment.  Despite  this,  remarkable  improve- 
ment was  obtained.  The  dosage  recommended 
is  15  to  40  grains  daily  of  fresh  gland  extract 
in  5-grain  tablets."     Since  this  was  published 


174     ESSAYS   ON  PRACTICAL   MEDICINE 

I  have  not  used  this  treatment  in  Graves' 
disease,  as  I  have  had  such  good  results  from 
parathyroid,  but  with  such  testimony  it  is 
clearly  a  weapon  in  reserve. 

Another  nervous  defect  successfully  treated 
by  it  is  impotence  in  the  male.  Several  cases 
of  complete  cure  have  been  reported  by 
Stalwagen  in  the  New  York  Medical  Journal, 
1 916.  There  are  also  favourable  reports  of  its 
use  in  epilepsy.  From  my  own  observation 
on  others  and  on  myself,  I  think  we  shall  find 
pitglandin  a  valuable  restorer  of  power  both 
physical  and  mental  in  the  feebleness  of  old  age. 
From  its  intimate  connection  in  early  life  with 
the  process  of  growth,  and  especially  perhaps 
with  the  development  of  the  gonads,  one 
would  expect  to  find  some  stimulating,  renew- 
ing effect  on  the  nervous  system  all  through 
life,  and  apparently  such  is  the  case.  As 
Brown-Sequard  found  new  energy  from  testi- 
cular extract,  so  I  think  we  shall  get  similar 
and  more  extended  effects  from  this. 

There  are  many  polyglandular  preparations 
of  value  on  the  market,  Carnrick  of  New  York 
with  his  very  valuable  hormotones  leading  the 
way. 

The  early  preparations  of  most  makers  con- 


SPECULATIONS  AND   DOUBTS         175 

tained  whole  pituitary,  and  were  very  useful 
as  nerve  tonics  in  neurasthenic  states.  They 
were  found,  however,  in  elderly  people  to  ra,ise 
blood-pressure  unduly,  and  so  others  have 
been  issued  without  the  pituitary  ;  a  still  later 
and  more  valuable  issue  is  a  polyglandular 
tablet  containing  thyroid,  ovary,  testis  and 
pitglandin  alone. 

Dr.  Leonard  Williams,  who  has  done  such 
good  work  as  an  apostle  of  endocrine  treatment 
in  this  country,  says  that  whole  pituitary  extract 
does  not  raise  blood-pressure  when  given  by  the 
mouth.  I  hesitate  much  to  differ  with  him, 
but  my  experience  has  led  me  into  the  opposite 
opinion.  My  working  rule  is  to  give  the  com- 
bination with  whole  pituitary  when  the  blood- 
pressure  is  normal  or  below,  and  to  substitute 
half  or  a  quarter  of  a  grain  of  pitglandin  when 
the  pressure  is  above ;  the  pitglandin,  I  feel 
sure,  helps  the  thyroid  to  lower  pressure,  and 
acts  at  the  same  time  as  a  general  nerve  tonic 
or  stimulant.  There  are  very  few  men  or  women 
above  fifty  who  are  not  the  better  for  a  little 
thyroid,  and  the  older  one  grows  the  more  one 
wants  it,  and  pitglandin  more  than  counteracts 
its  slightly  depressing  effect.  I  should  like  to 
ask  my  medical  confreres,  who  are  ageing  and 


176     ESSAYS  ON  PRACTICAL   MEDICINE 

who  are  feeling  the  burden  of  their  years  and  of 
their  toil,  to  try  it  on  themselves.  I  feel  sure 
they  will  find  their  capacity  for  work  increase, 
its  quahty  improved,  and  that  their  labours 
will  become  again  a  pleasure  instead  of  a 
drudgery. 

Of  the  things,  then,  that  we  have  spoken  this 
is  the  sum.  The  old  Romans  in  their  deep 
wisdom  and  insight  recognised  an  unseen  force 
that  in  our  bodies  was  ever  fighting  the  battle 
of  health  versus  disease,  of  life  versus  death. 
This  they  called  the  "  Vis  medicatrix  naturse." 
Of  this  power  till  now  we  have  known  but  Httle 
more  than  this  happy  name.  Harvey's  dis- 
covery of  the  circulation  of  the  blood  was  an 
enormous  advance,  but  was  no  solution  of 
the  mystery.  But  when  we  ponder  on  these 
internal  glands,  their  secretions,  which  are 
essential  to  life  itself,  their  intimate  correla- 
tions and  their  extraordinary  powers,  we  are 
tempted  in  the  first  flush  of  our  enthusiasm  to 
cry  out,  like  St.  Paul  to  the  Athenians,  "  That 
power,  that  vim,  which  ye  ignorantly  worship, 
that  declare  we  unto  you."  And  yet,  on  deeper 
reflection,  we  come  to  feel  that  it  is  still  not 
the  power  that  we  see,  but  only  the  Great 
Architect's   marvellous   mechanism :    and   so 


SPECULATIONS   AND   MVBTS         \^1 

we  become  humble  again,     Our  knowledge  has 
grown  immeasurably,  our  usefulness  has  grown, 
and  with  them  our  wonder  and  our  worship, 
In    scientific   language,    Biedl   sums   up    the 
present  position  of  our  knowledge  thus  :  "  Two 
agents  are  concerned  in  ordering  and  main- 
taining the  complex  activity  of  the  animal 
organism  ;    in  addition  to  the  nervous  com- 
munication, which  admittedly  is  the  agent  in 
effecting  rapid  readjustments,  there  is  also  a 
chemical  correlation  of  the  different  organs  ; 
in  accordance  with  the  latter,  each  organ,  each 
tissue,  and  even  each  cell  by  means  of  its  specific 
secretory  products,  acting  through  the  agency 
of  the  blood-stream,  is  enabled  to  exert  a 
specific  influence  upon  other  parts  of  the  body. 
In  this  manner  the  equilibrium  of  the  various 
parts  is  maintained." 

In  simpler  but  more  poetical  language  St. 
Paul  expresses  the  same  truth  :  * '  And  whether 
one  member  suffer,  all  the  members  suffer  with 
it,  or  one  member  be  honoured,  all  the  members 
rejoice  with  it."  The  condition,  then,  that  we 
call  perfect  health  implies  a  perfect  balancing 
or  equilibrium  of  all  our  organs  and  powers. 
To  maintain  this  balance,  or  to  regain  it,  if 
it  be  for  a  time  lost,  is  mercifully  the  Divine 

12 


17^    ESSAYS   ON  PRACTICAL   MED t CINE 

order,  the  implanted  tendency  in  all.  We  may 
so  fight  against  or  ignore  the  laws  of  Nature 
that  this  balance  is  never  perfect,  and  it  is 
thus  that  chronic  disease  arises  and  gains  the 
mastery. 

The  strange  and  unexpected  results  that  we 
sometimes  see  arise  from  so-called  faith  healing 
and  Christian  Science  can,  I  think,  be  thus 
scientifically  explained.  Under  the  influence 
of  great  emotions,  of  joy  or  hope,  and  also  of 
religious  fervour,  some  of  us  seem  to  have  the 
power  of  caUing  on  our  dormant  reserves  and 
of  increasing  the  output  into  the  blood  of  all 
our  home-made  autacoids  ;  this  often  results 
in  improvement  of  health,  and  in  some  cases 
even  of  cure.  It  is  surely  not  for  us  to  throw 
on  poor  struggling  mortals  the  cold  douche  of 
C5niical  semi-scientific  scepticism,  but  rather 
to  encourage  them  in  their  spontaneous  efforts, 
and  to  let  them  see  that  we  can  supplement 
their  own  natural  powers  from  outside. 

With  this  new  knowledge  of  the  "  Vis  medi- 
catrix,"  of  its  mechanism  and  of  its  chemistry, 
we  must  realise  that  our  control  over  disease 
is  enormously  increased,  and  that  there  is  a 
far  brighter  and  less  suffering  future  for  the 
sons  of  men. 


SPECULATIONS  AND  DOUBTS        179 

Whether  this  essay  will  have  on  the  minds 
of  my  readers  a  hormonic  or  a  chalonic  effect 
I  know  not,  but  I  venture  to  hope  that  the 
absorbing  interest  of  the  subject  will  cause 
them  to  forget  or  at  any  rate  to  forgive  the 
shortcomings  of  the  writer. 


IV 

CHRONIC  BRONCHITIS  AND  BRONCHIAL 
ASTHMA 

The  Microbe. — "Apologia  pro  Vita  Mea." 

Blindly  we  seem  to  labour. 

Whether  for  good  or  for  ill ; 
But  God,  all-seeing,  who  made  us. 

Knows  we  are  working  His  will. 

Patient  unceasing  toilers, 

In  the  welter  of  growth  and  decay 

We  further  the  infinite  purpose 
Of  His  wondrous  alchemy. 

In  this  essay  I  propose  to  deal  with  chronic 
bronchitis  and  its  frequent  sequel,  which  is 
generally  called  bronchial  asthma.  The  disease 
called  pure  spasmodic  asthma,  which  may  begin 
at  any  rate  without  bronchitis,  I  shall  only 
mention  incidentally.  Especially  in  the  large 
cities  with  impure,  smoky  atmospheres,  this 
disease,  as  we  all  know,  gives  us  a  large  part  of 
our  work,  and  often  gives  as  much  worry  and 
discontent,  but  that  is  of  little  consequence 
compared  with  the  wretched  health  and  the 

i8o 


BRONCHITIS  A  ND  BRONCHIA  L  A  STHMA     1 8 1 

crippling  of  work  and  energy  that  it  causes  in 
our  patients.  It  leads  also,  without  saying,  to 
shortening  of  life.  The  original  causes  are  not 
always  the  same.  It  may  begin  by  frequent 
attacks  of  simple  catarrh,  it  may  begin  from 
influenza,  from  slight  attacks  of  pneumonia 
or  bronchitis,  or  it  may  be  caused  by  continued 
inhalation  of  irritant  particles  or  gases.  Among 
men  and  women  who  have  to  live  and  work  in 
unhealthy  surroundings,  we  have  to  fight  this 
disease  chiefly  in  its  own  lair — change  of  air 
and  work  are  rarely  possible — and  this  is  a 
fight  which  needs  all  the  weapons  that  modern 
science  can  give  us,  all  our  patience  and  all  our 
skill ;  but  when  one  considers  the  results,  it  is 
a  fight  worth  the  fighting. 

Whatever  the  original  cause  of  this  con- 
dition may  be,  we  find  that  in  almost  every  case 
we  have  a  microbic  infection  to  deal  with. 
It  is  very  rarely  indeed  that  one  finds  the 
sputum  sterile.  The  microbes  that  we  find 
are  chiefly — and  I  am  trying  to  give  them  in 
the  order  of  their  frequency — M.  catarrhalis> 
pneumococcus,  and  one  or  other  variety  of 
staphylococcus  or  of  streptococcus  ;  the  Fried- 
lander  is  also  occasionally  found.  When  one 
has  treated  these  microbes  with  autogenous 


1 82     ESSAYS  ON  PRACTICAL    MEDICINE 

vaccines,  and  has  watched  and  weighed  the 
results,  one  must,  I  think,  arrive  at  the  conclu- 
sion that  they  are  the  chief  causes  that  main- 
tain and  perpetuate  the  chronic  disease.  I  am 
by  no  means  claiming  that  we  always  get  good 
effects  from  this  treatment,  but  the  number 
of  cases  that  are  either  cured  or  much  relieved 
is  so  great  and  so  far  in  excess  of  the  failures 
that  I  can  come  to  no  other  conclusion.  In 
fact,  I  have  almost  come  to  the  further  conclu- 
sion that  failure  is  the  result  of  some  error 
either  in  selection  of  the  microbes  or  in  the 
technique  of  the  preparations.  The  number- 
less cases  that  have  been  cured  by  this  method 
during  the  last  few  years  should  encourage 
us  to  further  scientific  investigation,  and  the 
failures  should  only  serve  to  show  us  our 
defects. 

There  is  one  point  that  I  must  emphasise 
in  this  place — that  is,  the  importance  of 
a  good,  careful  bacteriologist.  The  prepara- 
tion of  these  vaccines,  if  done  in  a  careless, 
haphazard  way,  will  only  lead  to  failure  and 
disappointment ;  and,  what  is  perhaps  worse, 
will  cast  a  stigma  on  us  and  on  that  subject  of 
pride,  our  medical  science.  I  am  not  speak- 
ing like  this  without  reason,  for  even  in  large. 


BRONCHITIS  AND  BRONCHIAL  ASTHMA     183 

well-known  bacterial  laboratories  I  have  known 
very  poor  work  done.  I  am  inclined  to  think 
that  private  workers,  and  if  possible  qualified 
medical  men,  will  oftentimes  make  better 
vaccines  than  institutions,  where  individual 
watching  is  often  impossible.  As  an  example, 
we  who  have  any  considerable  experience  of 
these  methods  must  have  come  across  cases 
which  have  been  cured  by  one  man's  vaccine 
when  another  man's  has  totally  failed.  It  is 
perhaps  hardly  necessary  to  say  that  all  vac- 
cines for  this  disease  should  be  autogenous, 
and  yet  I  have  known  stock  vaccines  to  be 
sent  out  and  recommended  as  equally  good. 

Hitherto  I  have  been  looking  at  this  disease 
from  the  point  of  view  only  of  the  invader,  and 
I  have  been  considering  only  the  destruction 
of  the  enemy  by  our  artillery.  The  wise 
physician  will  soon  see  that  this  is  only  part 
of  the  problem.  The  patient  who  has  un- 
luckily got  the  disease  is  really  the  man  who 
has  to  do  the  fighting  ;  we  can  help  him  much 
by  attacking  the  enemy  from  without,  but  we 
must  also  teach  him  and  help  him  to  put  his 
natural  defences  in  order.  Strictly  speaking, 
we  must  look  on  these  poisonous  bacteria  as 
foreigners,  but  as  a  matter  of  fact  they  are 


1 84     ESSAYS   ON  PRACTICAL   MEDICINE 

almost  always  with  us.  Very  rarely  does  a 
microscopical  examination  of  the  mucus  of  the 
nose  or  mouth  fail  to  show  the  presence  of  one 
or  other  of  them,  even  in  health.  Our  natural 
powers  of  resistance,  our  internal  secretions 
and  our  phagocytes  are  generally  able  to  deal 
with  them  effectually,  and  to  ward  off  their 
importunities  ;  but  it  is  when  these  poweis  fail 
or  are  caught  napping,  when  the  bacteria 
multiply  by  millions  and  there  is  nothing  to 
destroy  them,  when  they  pass  out  of  their 
place  and  invade  the  internal  organs,  that 
disease  is  established.  The  prevention  of  this 
failure  of  resisting  power  must  be  our  first 
aim.  Overwork,  intemperance,  improper  feed- 
ing, exposure  to  damp  and  chill,  all  tend  to  lower 
the  vitality  and  to  expose  us  to  attack.  These 
we  must  fight  as  best  we  can  and  as  circum- 
stances allow.  The  enemy  is  always  round  the 
corner  waiting  for  his  chance.  It  is  to  our 
frontiers  that  we  must  always  be  looking. 

Our  most  vulnerable  points  are  probably  the 
nose  and  mouth.  The  nose  in  health  should  act 
as  a  dust  and  germ  filter  so  effectually  that  no 
live  germ  should  gain  entrance  into  our  system, 
but  the  mucous  membrane  of  the  nose,  espe- 
cially in  impure  atmospheres,  often  becomes 


BRONCHITIS  A  ND  BRONCHIA L  A  STHMA     1 85 

irritated  and  thickened,  and  proper  nose  breath- 
ing becomes  a  difficult  thing  ;  then  mouth 
breathing  becomes  more  or  less  a  habit.  This, 
though  a  natural  passage  for  air,  is  not  an  effec- 
tive filter.  One  sees  how  very  liable  children 
with  adenoids  are  to  bronchitis  and  bronchial 
asthma.  The  nose,  then,  is  the  first  point  to 
attend  to.  The  physicians  and  surgeons  who 
have  devoted  themselves  to  this  branch  of  work 
can  often  give  us  great  help,  by  restoring  a 
proper  nasal  passage  and  by  attention  to  the 
tonsils.  There  is  often  a  congested  tender  spot 
in  one  or  both  nostrils,  which  seems  to  act  as 
a  centre  from  which  proceed  the  nerve  storms 
that  cause  spasmodic  asthma.  Here,  also,  hay 
fever  seems  to  originate.  This  spot  needs  great 
care  in  treatment,  and  harm  can  easily  be 
done ;  but  some  of  our  chief  specialists,  by 
their  skill,  produce  in  these  cases  something 
like  a  miraculous  revolution.  Our  largest 
frontier,  of  course,  is  the  skin,  and  this  many 
working  folk  habitually  neglect.  Their  work 
often  causes  sweating,  and  the  skin  that  sweats 
needs  careful  washing  and  protection.  They 
often  wear  clothes  that  do  not  absorb  the 
moisture,  and  so,  when  work  ceases,  their  skin 
is  in  contact  with  a  damp,  chilly  material. 


i86     ESSAYS   ON  PRACTICAL   MEDICINE 

Much  may  be  done  by  bathing  and  after-rubbing 
with  a  rough  towel  to  keep  the  circulation  of 
the  skin  in  a  healthy  resisting  state.  Bron- 
chial folk,  as  a  rule,  cannot  stand  a  cold  bath, 
and  a  hot  bath  often  relaxes  the  pores  and 
leaves  them  Hable  to  chill.  The  best  plan  is 
to  thoroughly  wash  and  soap  in  hot  water, 
and  then,  standing  up  with  the  feet  still  in  the 
hot  water,  to  have  two  or  three  good  sponges 
down  with  cold  water,  beginning  at  the  head. 
This  produces  a  good  reaction  of  the  circulation 
and  is  a  pleasant  stimulant.  The  clothing 
should  be  not  too  light,  nor  so  heavy  as  to 
produce  perspiration  when  not  at  work.  Light 
woollen  materials  are,  I  think,  the  best,  but 
some  of  the  modern  cellular  makes  of  cotton 
seem  to  answer  well. 

It  is  clear,  then,  that  any  one  with  a  tendency 
to  bronchial  catarrh  or  asthma  needs  to  lead 
a  most  careful  and  watchful  life  ;  he  is  inces- 
santly almost  open  to  attack  from  hostile 
germs,  and  every  chill  weakens  his  defences. 
We,  on  our  part,  can  do  much  to  help  these 
cases  by  looking  to  the  heart  and  blood-vessels, 
the  digestion  and  the  kidneys.  Many  of  these 
patients,  especially  in  middle  Hfe,  have  over- 
strained, dilated  hearts,  and  often  some  degree 


BRONCHITIS  AND  BRONCHIAL  ASTHMA     187 

of  arterio-sclerosis,  and  there  may  be  early 
kidney  trouble.  The  action  of  the  liver  often 
is  sluggish  and  the  organ  may  be  congested  ; 
this,  of  course,  causes  indigestion  and  the  flatu- 
lence which  bothers  many  of  them  so  much. 
Careful  attention  to  all  these  points  will  help 
much  towards  cure,  especially  in  conjunction 
with  the  vaccine  treatment.  To  gain  real 
success  the  old  therapeutics  and  the  new  must 
go  hand  in  hand. 

There  is  a  distinctly  gouty  form  of  chronic 
bronchitis  which  often  alternates  with  true 
gout  and  eczema.  This,  in  the  first  instance, 
will  only  yield  to  appropriate  gouty  treatment  : 
alkalies,  sulphur,  etc.  ;  but  even  this  form 
becomes  bacterial  in  the  end,  and  the  sputum 
should  always  be  examined.  Most  of  the 
remedies  (and  they  are  almost  innumerable) 
that  we  have  used  empirically  in  the  past  have 
acted  chiefly  as  bactericides — for  example,  the 
tars,  turpentine,  terebene,  the  balsams,  the 
benzoates ;  the  great  favourite,  iodide  of 
potassium,  acts  probably  in  this  way  directly 
by  its  iodine  and  indirectly  by  stimulating 
the  output  of  thyroid  secretion.  Chloride  of 
ammonium,  again,  probably  acts  in  the  same 
way.      Antimony,  which  in  the  acute  early 


i88     ESSAYS  ON   PRACTICAL    MEDICINE 

stages  of  bronchitis  was  our  forefathers'  sheet- 
anchor,  and  which  has  fallen  out  of  use  far 
too  much,  is  probably  a  bactericide  [vide  its 
action  on  trypanosomes).  While  carrying  out 
the  vaccine  treatment,  even  if  there  be  no 
cardiac  complication,  the  patient  will  need 
helping  in  every  possible  way.  Arsenic  and 
iron  are  often  very  useful.  The  judicious  use 
of  internal  secretion  preparations  will  often 
help  wonderfully.  In  cases  with  high  tension 
and  threatening  arterio-sclerosis,  thyroid  will 
often  bring  about  a  better  state  of  general 
health  and  help  to  reduce  abnormal  deposits 
of  fat  about  the  heart.  In  others  suprarenal 
extract  will  do  good,  especially  if  arterial  ten- 
sion be  low  ;  in  others  one  of  the  polyglandular 
preparations  will  raise  the  general  tone  and 
resisting  power. 

When  we  come  to  the  practical  use  of  vac- 
cines, we  have  first  to  find  out  what  the  sputum 
contains — for  there  will  rarely  be  only  one 
enemy — and  then  to  decide  on  a  single  or 
multiple  vaccine.  I  think  we  must  give 
pneumococcus  the  place  of  honour.  He  is  as 
common  as  any  and  perhaps  the  most  easily 
cured.  It  is  very  surprising  how  many  cases 
of  chronic  bronchitis,  with  or  without  asthma. 


BRONCHITIS  A  ND  BRONCHIA  L  A  STHMA    1 89 

have  pneumococci,  even  when  there  is  no  history 
of  any  attack  that  one  can  suspect  of  being 
true  pneumonia.  One  must,  I  think,  come 
to  the  conclusion  that  many  attacks  of  acute 
bronchitis  are  pneumococcic  in  origin,  even 
when  there  have  been  no  signs  of  lung  con- 
solidation or  of  rusty  sputum.  In  the  British 
Medical  Journal  of  June  14,  1913,  Dr.  Pirie, 
in  an  article  that  is  very  instructive  both  to 
the  physician  and  to  the  bacteriologist,  gives 
the  following  statistics. 

Bacteriology   of   sixteen    cases   of   chronip 
bronchitis  without  asthma  : 


Pneumococci    . 

.     12  cases 

M.   catarrhalis 

.     12     „ 

Staphylococci   . 

•       5     » 

Streptococci 

.       6     „ 

Friedlander 

.       5     „ 

In  sixteen  cases  of  chronic  bronchial  asthma 
he  found  : 


Pneumococci    . 

.     16  cases 

M.  catarrhalis  . 

.     16     „ 

Staphylococci   . 

.       8     „ 

Streptococci      . 

.       6     „ 

Friedlander 

.       6     „ 

rgo     ESSAYS   ON   PRACTICAL   MEDICINE 

The  almost  universal  absence  or  non-dis- 
covery of  the  influenza  bacillus,  even  with  a 
clear  history  of  a  recent  attack,  is  remarkable. 
The  selection  will,  to  a  certain  extent,  depend 
on  the  predominance  of  one  or  other  bacillus 
in  the  culture,  and  generally  speaking  a  mul- 
tiple vaccine,  with  the  possible  exception  of 
pneumococcus,  is  more  likely  to  be  effectual 
than  a  single  one.  The  following  is  the  ex- 
perience of  my  son,  Dr.  Arthur  Scott,  who  has 
for  the  last  five  years  made  most  of  my 
vaccines  : 

"  Much  disappointment  and  doubt  as  to  the 
value  of  vaccines  in  chronic  chest  complaints 
is,  I  beHeve,  prevalent  among  the  medical  pro- 
fession. Yet  I  think  that  those  medical  men 
who  have  given  them,  in  chronic  cases,  frequent 
and  prolonged  trial  become  more  and  more 
convinced  of  their  general  value  ;  I  say  gene- 
ral value,  for  one  meets  with  many  failures  in 
cases  which  one  thinks  would  promise  well. 
Granted  a  definite  curative  value  in  vaccines, 
it  becomes  difficult  to  explain  their  complete 
failure  in  certain  cases.  Making  an  attempt 
to  group  these  causes  of  failure,  there  is  in 
the  first  place  the  unknown  condition  in  some 
patients   that  negatives  immunity  :     for   ex- 


BRONCHITIS  AND  BRONCHIAL  A STHMA    igi 

ample,  from  an  attack  of  measles  one  person 
becomes  immune  for  life,  another  may  get  it 
again  in  a  few  months.  It  seems  that  there 
is  a  failure  on  the  part  of  some  patients  to 
retain  their  anti-bodies  in  the  system. 

"  In  a  second  group,  and  it  is  a  large  one, 
the  vaccine  is  at  fault.  In  nearly  all  bronchial 
cases  there  is  a  mixed  infection,  and  the  diffi- 
culty in  choosing  from  which  bacteria  to 
make  the  vaccine  arises.  Make  a  separate 
vaccine  of  all  the  likely  bacteria  present  and 
mix  them  together  is  the  apparent  solution 
of  the  problem,  but  this  entails  making  sub- 
cultures into  several  generations,  and  vaccines 
from  subcultures  have  very  Httle  power  of 
conferring  immunity.  Probably  the  most 
efficient  way  is  to  make  a  solution  from  the 
primary  culture,  then  estimate  the  relative 
proportions  of  the  varieties  of  bacteria  to 
each  other,  by  naked-eye  examination  of  the 
cultures  (this  is  rather  guess-work),  or  where 
possible  by  examining  a  prepared  slide  of  the 
solution.  The  predominating  variety  is  then 
not  subcultured,  but  the  varieties  occurring  in 
small  numbers  are  subcultured  and  added  to 
the  original  solution  in  proportion  to  the  dose 
required  for  administration.     This  method  is 


1^2     ESSAYS   ON  PRACTICAL   MEDICIN:^ 

necessarily  faulty,  but  not  more  so  than  the 
use  of  impure  subcultures  of  all  the  varieties. 
Subcultures  can  only  be  obtained  pure  after 
several  generations  have  been  made. 

"  Often  the  method  of  sterilisation  of  the 
vaccine  destroys  its  value  :  for  example,  a 
pneumococcal  vaccine  begins  to  lose  its  virtue 
when  heated  to  55°  C,  whereas  a  staphylo- 
coccal vaccine  may  not  be  killed  at  60°  C. 
This  explanation  shows  that  it  is  not  neces- 
sarily the  principle  of  vaccination  that  is  the 
cause  of  failure,  but  often  the  so  far  insuperable 
difficulties  of  the  bacteriologist.  It  is  possible 
that  in  the  future  the  X-rays  may  help  to 
solve  some  of  these  difficulties. 

"  In  a  third  group  error  in  administration 
is  the  cause  of  failure.  The  size  of  the  doses 
and  the  intervals  between  them  can  only  be 
determined  by  the  patient's  symptoms.  The 
opsonic  index  will  not  help,  as  in  bronchial 
cases  it  is  a  question  of  local  or  tissue  immunity 
rather  than  of  general  immunity.  Of  more 
importance  than  all  is  the  duration  of  the 
treatment.  Most  patients  are  not  kept  under 
treatment  nearly  long  enough.  It  is  to  be 
remembered  that  the  bacteria  present  are 
probably  leading  a  saprophytic  as  well  as  a 


BRONCHITIS  AND  BRONCHIAL  ASTHMA    193 

parasitic  existence.  This  I  personally  believe 
to  be  always  the  case  in  chronic  bronchitis. 
Thus  the  organisms  present  are  living  not 
only  on  the  bronchial  epithelium  but  also  on 
the  bronchial  secretions  ;  these  are,  in  the  first 
place,  set  up  by  repeated  bacterial  attacks  on 
the  epithelial  cells,  which  are  then  kept  actively 
secreting  by  the  irritation  of  the  toxins,  a 
vicious  circle  being  thus  formed.  Hence,  if 
both  general  and  local  immunity  are  obtained, 
it  will  not  follow  that  the  symptoms  of  bron- 
chitis will  at  once  disappear,  for  the  sapro- 
phytic existence  of  the  bacteria  is  not  only 
active,  but  is  waiting  for  lowering  of  immunity 
to  attack  again.  For  these  reasons  I  think 
that  vaccine  treatment  of  chronic  chest 
catarrhs,  etc.,  should  be  continued  for  very 
much  longer  periods  of  time  than  is  now 
usually  done,  so  as  to  allow  the  bronchial 
epithelium  to  regain  a  normal,  healthy  con- 
dition. I  believe  that  in  old-standing  cases  of 
bronchial  asthma  treatment  of  less  than  two 
years'  duration  is  of  little  use.  The  vaccines 
will  not  need  to  be  given  very  frequently  after 
the  first  six  months  :  once  a  fortnight,  or  once 
in  three  weeks,  is  generally  sufiicient." 

From  my  own  experience  I  would  further 

13 


194     ESSAYS  ON   PRACTICAL   MEDICINE 

say  that  in  these  long-standing  cases  it  is  good 
policy  to  have  a  fresh  bacterial  examination 
made  every  six  months  or  so,  and  if  the  bac- 
terial conditions  have  altered,  to  have  a  fresh 
vaccine  made.  One  of  the  most  successful 
cases  I  have  ever  seen  is  an  old  lady,  now 
eighty-three  years  of  age,  who  lived  out  of 
England  for  many  years  in  the  hope  of  getting 
rid  of  persistent  bronchial  asthma.  She  finally 
came  to  Bournemouth  to  end  her  days  as  a 
hopeless  case.  She  has  been  under  treatment 
now  for  five  years,  having  a  vaccine,  which  is 
changed  from  time  to  time,  every  fortnight. 
tJnder  this  she  has  regained  a  very  fair  degree 
of  health,  and  the  bronchial  asthma  is  almost 
cured.  Age  is  no  bar  to  this  treatment.  Quite 
old  people  of  seventy-five  to  eighty-five  do 
very  well  and  get  no  alarming  symptoms. 
Children  also  of  two  or  three  years  old  re- 
spond equally  well.  The  most  disappointing 
cases,  perhaps,  are  in  overworked,  anxious, 
neurotic,  middle-aged  folk.  Confirmed  em- 
physema has,  by  some,  been  thought  to  be 
unsuitable  for  vaccines,  but  that  is  not  at 
all  my  experience.  On  the  contrary,  I  have 
seen  bad  cases  of  emphysema  very  much  im- 
proved, and  surely  it  is  only  what  one  would 


BRONCHITIS  AND  BRONCHI AL  ASTHMA   195 

expect ;   if  catarrh,  cough,  and  expectoration 
are  lessened  or  cured,  the  lung  substance  has 
again  a  chance  to  recover  its  elasticity.     As  I 
have   said   before,    pneumococci   cases   often 
respond  quickly  and  well.     Catarrhalis  cases 
vary,  but  are  generally  rather  obstinate,  and 
it  is  not  always  easy  to  find  the  suitable  dose 
to  begin  with.    Too  big  a  dose  will  sometimes 
increase  dyspnoea.     Staphylo  cases  are  gener- 
ally in  conjunction  with  pneumococci  or  more 
often  with  catarrhalis,  and  a  double  vaccine 
often  answers  well.      Streptococci  cases  will 
often  need  a  long  course,  but  do  very  well  in 
the  end.     This  microbe  will  not  seldom  be 
found  with  pneumococci.     It  is  well  to  begin 
with  a  small  dose,  ten  or  fifteen  millions,  and 
to  watch  for  symptoms  of  irritation  such  as 
increased  cough  or  dyspnoea  ;   a  rise  of  tem- 
perature is  very  rare,  and  if  it  occur  should 
cause  no  alarm.     The  smaller  doses  should  be 
given  every  four  or  five  days.    When  one  has 
found  the  dose  that  does  good,  it  is  better,  I 
think,  to  stick  to  it  and  to  give  it  every  ten 
days  or  so,  till  one  has  got  the  symptoms  well 
under  control,  and  then  to  carry  it  on  at  inter- 
vals of  every  two  or  three  weeks  for  a  year 
or  more. 


196     ESSAYS   ON  PRACTICAL   MEDICINE 

It  is  hardly  necessary  for  me  to  say  that  all 
vaccine  treatment  should  be  carried  through 
with  strict  antiseptic  precautions.  I  find  that 
washing  the  syringe  and  needle  inside  and  out 
with  a  weak  lysol  solution  is  a  quick  and  safe 
plan  ;  the  patient's  skin  should  be  cleaned 
with  the  same  solution  or  with  iodine.  If 
lysol  is  left  in  the  syringe  more  pain  is  caused 
than  is  necessary ;  so  I  wash  it  out,  before 
drawing  in  the  vaccine,  with  boiled  water. 
The  collection  of  sputum  should  be  done  in 
the  morning,  if  possible,  before  food  is  taken, 
and  the  mouth  should  be  washed  out  pre- 
viously with  hot  water,  not  with  any  antiseptic 
wash.  The  sputum  should  be  expectorated 
straight  into  a  wide-mouthed  bottle  with 
glass  stopper  that  has  been  sterihsed  by  boil- 
ing the  previous  night,  and  should  be  sent 
with  little  delay  to  the  examiner. 

In  many  of  these  cases  one  will  find  high 
tension  and  early  symptoms  of  arterio-sclero- 
sis  ;  this  has  been  thought  by  some  to  contra- 
indicate  vaccine,  but  my  experience  has,  with 
these  cases,  been  very  favourable.  The  high 
tension,  etc.,  has  been  to  a  large  extent 
brought  about  by  the  continual  strain  of 
coughing  and  dyspnoea  and  by  broken  rest. 


BRONCHITIS  AND  BRONCHIAL  ASTHMA    197 

and  the  relief  of  these  will  alone  lower  tension. 
It  is  very  common  for  old  people  who  have 
had  a  chronic  cough  to  die  of  a  sudden  un- 
explainable  pneumonia,  without  any  chill 
or  exposure  to  infection :  these  cases  are 
all  latent  pneumococcic  affections.  For  some 
reason  the  resisting  power  has  given  way,  and 
the  invasion  has  taken  place.  Such  cases 
could  be  easily  prevented  by  the  occasional 
use  of  pneumococcus  vaccine,  for  the  microbe 
could  have  been  detected  in  the  sputum  of 
the  chronic  state. 

Further,  arterio-sclerosis  is  thought  by  many 
to  be  caused  in  some  cases  by  auto-intoxica- 
tion from  the  abnormal  bacteria  of  the  diges- 
tive tract :  is  it  not  reasonable  to  think  that 
it  may  be  caused  also  by  auto-intoxication 
from  the  abnormal  bacteria  of  the  respiratory 
tract  ?  Whatever  the  cause  may  be,  you  will 
generally  have  the  satisfaction  of  seeing  the 
high  tension  satisfactorily  subside,  with  all  its 
accompanying  symptoms,  and  this  will  take 
place  without  using  any  depressor  remedies. 

With  such  a  varied  pathological  cause  for 
the  group  of  morbid  symptoms  that  we  call 
bronchial  asthma,  is  it  reasonable  to  expect 
that  any  medicinal  course  of  treatment,  either 


198     ESSAYS  ON   PRACTICAL   MEDICINE 

by  the  stomach  or  by  inhalation,  can  ever 
effect  a  radical  cure,  or  have  any  but  a  passing 
action  ?  A  symptom  here  and  there  can  be 
relieved  and  the  patient  made  more  comfort- 
able {vide  the  endless  list  of  patent  and  pro- 
prietary cures  that  are  no  cures).  As  scientific 
men  we  should  go,  if  possible,  to  the  lOots  of 
the  disease,  and  the  modern  science  of  bacteri- 
ology is  helping  us  to  do  this  most  effectually. 
We  have  much  to  learn,  and  something  to 
unlearn,  but  patience  and  honest  work  will 
produce  undreamt-of  results.  Finally,  I  look 
on  this  treatment  as  a  true  and  logical  ex- 
tension of  my  dream — organic  therapeutics. 


l^ONDON  :    H.  K.  I/EWIS  &  Co.  I,TD.,   136  GOWER  STREET,  W.Q.l 

PrinUd  by  Htucll,  Watson  &  Viney,  Ld.,  London  and  Aylesbury 


-   ?^>5^ 


> 


:P 


